More than a staffing issue: The behavioral health crisis is an operations challenge

Primary care physicians and OB-GYNs have become the default first point of contact for patients dealing with an array of mental health conditions spanning anxiety, depression, post-traumatic stress disorder, substance use disorders and maternal mental health concerns. Increasingly, primary care physicians and ob-gyns are serving as the entry point into behavioral health care because they are often the most accessible providers in the health care system.

Industry analysts tend to describe this as a workforce shortage, contending that there are not enough psychiatrists, not enough therapists and not enough hours in the day. Although this is a reality, it’s only part of the scenario. A growing body of evidence points to a second, less visible cause: outdated billing systems, fragmented credentialing processes and disconnected provider networks that make it structurally difficult for behavioral health providers and primary care physicians to work together, even when both sides have the desire to do so.

A crisis that extends beyond the provider shortage

There’s little dispute about clinical need. Current estimates show that up to one-third of primary care physicians and other clinicians now report that over 20% of their patients need mental or behavioral health treatment during visits.

Primary care physicians and OB-GYNs are increasingly expected to discover these concerns first, whether or not their practices are staffed or structured to act on what they detect.

But identifying a problem and getting a patient into treatment are two different things, and the gap between them is where the system tends to break down. There’s a growing consensus that this gap isn't primarily clinical. Rather, it's operational and rooted in reimbursement rules, credentialing bottlenecks and provider directories that don't reflect reality.

Why does behavioral health lag behind other specialties operationally?

While virtually every other medical specialty has spent decades standardizing reimbursement and administrative infrastructure, behavioral health has evolved largely outside these parameters. As a result, frictions have developed relative to this medical specialty.

Credential time lag

One of the most glaring examples is credentialing: Achieving recognition and approval for a behavioral health clinician to submit billable claims to a commercial payer typically requires 30 to 45 days at best. For government-sponsored plans such as Medicare and Medicaid, enrollment routinely runs 90 days or longer. Industry surveys have found credentialing backlogs for behavioral health and telehealth providers increasing by roughly 22% in a single year. A single outdated attestation, an expired license during the review window, or a misrouted application can send the process back to the beginning and add months, not days, to the timeline. During that entire window, a fully licensed, willing clinician cannot see an insured patient.

Unlike large health systems, many behavioral health clinicians practice independently or in small groups without dedicated credentialing or billing staff. Every payer application, follow-up request and missing document competes with time that could otherwise be spent seeing patients. As a result, administrative complexity has become a significant factor in whether clinicians participate in insurance networks at all. Simplifying credentialing is not merely an operational improvement; it is a prerequisite for expanding real-world access to behavioral health care.

Paying by what rules?

A second layer of friction stems from billing, as reimbursement rules for behavioral health services differ meaningfully by payer and by code. Moreover, documentation requirements are inconsistent, and the administrative overhead of tracking time-based codes correctly falls disproportionately on small practices that don't have the resources to engage dedicated billing staff. For many behavioral health clinicians, especially those in solo or small-group practice, the cost of navigating this system outweighs the benefit of joining a network at all, a factor which helps explain why so many opt to stay out-of-network entirely.

From the clinician’s perspective, the challenge is rarely a reluctance to serve insured patients. Rather, it is the cumulative burden of credentialing, reimbursement uncertainty and ongoing administrative maintenance that pulls providers away from patient care. The easier it becomes to participate in payer networks, the more clinicians are willing to make that investment.

Ghost networks

In turn, this fuels a third problem: inaccurate provider directories, sometimes called "ghost networks." A 2025 federal investigation found that 55% of behavioral health providers listed in sampled Medicare Advantage directories were inactive, and 28% were inactive in Medicaid managed care directories, reflecting providers who had not delivered a single service under that plan in a year.

In 2023, a separate Senate Finance Committee "secret shopper" study of mental health listings across a dozen Medicare Advantage plans found 80% of provider listings were inaccurate or unavailable, and one-third were unreachable altogether. This problem persists and has undoubtedly worsened over the past three years, with ongoing multiple state investigations, including a recent multimillion-dollar settlement over inflated behavioral health directories, pointing to the same underlying pattern nationally.

Why operational barriers translate into patient harm

These friction points might resemble a back-office problem, but collectively, they become a patient-facing crisis.

A physician who identifies a mental health condition and hands a patient a referral list is, in reality, simply turning the individual over to a scavenger hunt. Patients in need will be calling providers who no longer accept the plan, have no openings or don't return calls. Every dead end is not only disheartening but also adds to the delay.

Postponing treatments has its consequences since untreated behavioral health conditions worsen chronic disease control, drive avoidable emergency visits, and, in the most serious cases, contribute to crises that could have been identified earlier. While the shortage of providers is generating the widest attention, a provider panel that merely exists “on paper” and isn't reachable in practice produces the same outcome as a bevy of providers that really doesn't.

From the clinician’s perspective, administrative burden compounds the problems for behavioral health providers who spend disproportionate time on credentialing paperwork and claims follow-up — leaving them less time and less incentive to take on new patients. This conundrum restricts capacity even in markets that appear to have adequate coverage.

How does this affect primary care providers?

For primary care and OB-GYN practices, the operational gap shows up most acutely at the moment of referral, the point when a screening result is supposed to evolve into a treatment plan.

• Perinatal and maternal mental health. OB-GYNs routinely screen for postpartum depression and anxiety, and most take that responsibility seriously. But a positive screen is only useful if there's a workable path to a specialist who can see the patient promptly, particularly given the narrow window in which perinatal mental health conditions can escalate.
• Substance use disorder. Primary care physicians and other clinicians are often the first to notice risk factors tied to prescribing patterns or early substance use, and timely, coordinated intervention meaningfully changes outcomes. This obviously requires a clear, fast pathway to addiction treatment resources, not a static database of numbers that may or may not connect.
• Autism and other neurodevelopmental conditions. Early identification frequently happens in a pediatric primary care visit, and the evidence is clear that earlier intervention improves outcomes. Families referred into an inaccurate or unresponsive network can lose months at exactly the developmental stage when time matters most.

In each case, the clinical instinct is sound. What's missing is the connective tissue that leads patients to accurate networks, workable referral pathways and administrative systems that don't collapse under their own complexity. The goal is to turn that instinct into completed care.

Building the infrastructure for integrated care

Continued investment in workforce development must continue, as the U.S. does need more behavioral health clinicians. But the real solution to improving access will also require modernizing the infrastructure around clinician practices.

Here’s what is needed: Simplifying and centralizing credentialing so that a qualified clinician can become billable in weeks rather than months, and avoiding restarting the process over a lapsed verification. This also merits sufficiently standardizing behavioral health billing and reimbursement rules so that a small practice can navigate the landscape in the absence of a dedicated compliance staff.

Patients need a provider directory that reflects which clinician is actually available, rather than naming one who may have signed a contract years ago. These ghost networks have drawn direct regulatory scrutiny at both the state and federal levels.

Finally, building genuine interoperability between physical and behavioral health records should become mandatory, so that a referral doesn't require a patient to reexplain their history to a provider working from a blank chart.

Some of this work falls to payers and regulators. Some initiatives are being addressed through emerging administrative and technology platforms designed specifically to streamline credentialing, verify network accuracy in real time and connect primary care practices to behavioral health providers who are actually available. The vision is to create an infrastructure aimed at the operational layer rather than the clinical level. As practices evaluate where to invest — staff, technology or partnerships — they should weigh candidates against that same standard: Does this actually shorten the distance between a positive screen and a patient in treatment?

The bottom line

Integrating behavioral health into primary care is not simply a clinical challenge; it is an operational task worth executing. The aspiration to expand access will require more than recruiting additional clinicians. It will require the systems, reimbursement models and care pathways that enable physical and behavioral health providers to work together seamlessly. The clinical intent to integrate behavioral health into primary care already exists among most physicians. What's still missing, in far too many practices and markets, is the operational infrastructure that ensures meaningful, useful and productive actions that optimize clinical patient outcomes.

Trevor Colhoun is the CEO and co-founder of TPN.health, the nation’s digital home for behavioral health providers, with more than 100,000 clinicians across all 50 states. The platform has powered over 450,000 continuing education hours and more than 300,000 events, making it the most trusted space for providers to connect, learn and advance their professional growth.

Kolby Nance, M.C.C., is president of TPN.match, where he leads the team focused on clinically matching clients with their best-fit therapist. He is a licensed mental health counselor, entrepreneur, and behavioral health technologist with experience spanning private practice, consulting and care navigation technology.