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Insurance Audits: OPA can help!

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Yesterday

On March 1, I assumed my role as your new Director of Professional Affairs.  As many of you likely know, I follow in the footsteps of Dr. Bobbie Celeste, a very tough act to follow to say the least.  Many of you may be less aware, however, that some OPA staff duties and responsibilities have been reorganized, and that one of my main duties in this role will be to help our members troubleshoot the many insurance issues which continually crop up for us as psychologists. Fortunately, my experience as the owner of a busy private practice and my time spent as chair of OPA’s Insurance Committee have helped prepare me for this job.  It is becoming increasingly clear to me that, not only is this role new for me, but I have the opportunity to shape the DPA role for the association.  

I am coming to realize very quickly that I must maintain two high priorities as your DPA: 1) to monitor, learn about, and provide support for the everchanging challenges which emerge for psychologists as you interact with the world of insurance companies; and 2) communicate often and clearly my best understanding of how to navigate these rough waters.  My intention is to do this through emails such as this, as well as through my blog on the OPA website and our social media.  If insurance issues affect you, look for these communications and feel free to contact me and give feedback.

As those of you who follow the OPA’s general listserv know, my efforts to help with these insurance issues have been required in the last two weeks.  Many psychologists who are Medical Mutual providers have received letters from Change Healthcare, a company who has contracted with the insurance carrier to provide auditing for them.  The form letter received by our members essentially expressed concern that some psychologists are overbilling psychotherapy code 90837.  Those of us who have worked with insurance issues for some time recognize these letters as the latest example of a larger effort on behalf of the entire insurance industry to discourage the use of a commonly used psychotherapy session time (CPT 90837—60 minutes) and encourage the use of a shorter one (CPT 90834—45 minutes).  As so many of our many members have observed, these efforts have been ongoing absent any clearly articulated research or clinical effectiveness based rational.  

Fortunately, at the state and national level, we have experience working with this issue.  In 2016, another insurance carrier, Anthem Blue Cross Blue Shield, made similar efforts through an auditing company with whom they contracted, EquiClaim.  A number of letters similar to those sent out by Change Healthcare were received by our members from EquiClaim in early 2016. Following this, OPA reached out to APA’s office of Legal and Regulatory Affairs.  Their staff attorneys were able to intervene with Anthem, and the results were positive.  These results were summarized in an article published on APA’s website in March, 2016:

Practice Organization members have reported receiving letters about the frequency of their use of CPT® code 90837 (psychotherapy, 60 minutes with patient and/or family member). These letters, sent by EquiClaim on behalf of Anthem Blue Cross Blue Shield, were addressed to psychologists allegedly using 90837 more than average for Anthem psychologists.

The letters indicate they are for informational purposes; however additional language states EquiClaim’s monitoring of the psychologist’s 90837 billing practices may lead to a request for “medical records of members with the intention of identifying any improper coding and recovering associated overpayments.” Members expressed concern that continued use of 90837 might result in an audit and refund demands.

Practice Legal and Regulatory Affairs staff has developed a good relationship with leaders at Anthem. Using a collaborative approach (which proved successful with the Santé Analytics and Inovalon audits), we contacted Anthem to clarify the meaning and intent of the EquiClaim letters. Anthem promptly provided a statement (PDF, 102KB) assuring us that this is an educational process without financial consequences. 

In response to our concerns about these letters, Anthem has made changes internally to ensure further reviews of these types of communications occur in advance of distribution.


As I write, these same APA staff attorneys are reaching out Medical Mutual representatives in an effort identify similar solutions.  I will be happy to keep you updated on their results.  (I remind myself that this is the reason I pay my APAPO dues!)

I look forward to continuing these regular communications with you.  Feel free to share your thoughts!

Jim Broyles, Ph.D.
OPA Director of Professional Affairs

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Medical Mutual Audit

Posted By Karen J. Hardin, Friday, March 24, 2017
Updated: Friday, March 24, 2017
I am taking some time this morning to review my efforts in advocating for us on this issue.  I have received or have become aware of a couple of other points of information I will be forwarding to APA to support them in their effort to assist us.  As I review the posts here on this thread, I become appreciative of this passionate, robust conversation.  It strikes me that, during moments like this, so many are moved to speak their truth about what we do as psychologists, and how we are often hampered in our efforts by entities and organizations who have little understanding of our work.  At the same time, I want to encourage all of you to be willing to do more.

Dr. Lewis makes some excellent points about the value of psychologists, and the unique skills which set us apart as from other mental health professionals.  Did you know that OPA has a Marketing Task Force?  This small group has been meeting and working regularly for some time. Its job has been to develop marketing strategies to shape public perception of our unique strengths and skills as psychologists.  As an association, our thinking is that if we can help the more general public understand the unique strengths and skills psychologists possess compared to other mental health professionals, it becomes more difficult for insurance companies to identify us as equivalent to other kinds of professionals on their panels.  The Marketing Task Force meets once week via conference call and could use more members to help accomplish its purpose.

Did you know that OPA has an Insurance Committee?  This committee's purpose is to tackle these very thorny difficulties which arise when insurance companies, whose actions so clearly affect all our lives, develop a new policy or procedure which reflects so little understanding of best practice within our profession and ultimately hampers our effectiveness.  It is the committee's job to develop and implement strategies to respond to the problems and barriers created by these companies like the one under discussion here.  This group meets once per month via conference call and would also benefit from more members who are energized to take some action.

My point here is that I am aware we are all very busy and often do not think about taking an action to tackle a problem until it touches our lives in a very obvious and painful way.  However, from the larger perspective of our association, efforts to tackle these problems have been ongoing for some time.  Change only becomes possible when we come together, and in OPA the work of coming together for collective action occurs in our committees.  If anyone reading this post is interested in joining these ongoing efforts, please contact me.

Jim Broyles, Ph.D.
OPA Director of Professional Affairs

Tags:  Insurance  Insurance Committee  Medical Mutual Audit 

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Affordable Care Act Replacement Legislation - Act Now!

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Thursday, March 9, 2017
I recently had the privilege of attending APA’s Practice Leadership Conference as OPA’s new Director of Professional Affairs. As many of you may know, an important feature of the conference is the attendee’s advocacy efforts on behalf of professional psychology at the national level. State leaders participate in a series of meetings with their respective state’s senators and representatives to advocate for key issues which affect our profession. The impending changes in the Affordable Care Act currently being considered by Congress were obviously at the top of our list of crucial issues to discuss. Most of our direct interaction was with Legislative Assistants from each Member’s office, and on the eve of our scheduled appointments, the ACA replacement legislation was formally introduced to Congress. As you may imagine, a disquieting attitude gripped Capitol Hill this past Tuesday as our discussions moved forward. Among the most productive moments for some members of our Ohio delegation was the meeting in Senator Sherrod Brown’s office. The Senator’s assistant with whom we met shared our concern about the changes which were quickly evolving and the potential for negative impact on so many if careful deliberation were not applied by key decision makers. She was appreciative of our core request as psychologists: do not repeal the ACA without simultaneously enacting replacement legislation which preserves reliable coverage for mental health and substance use disorder treatment at parity with coverage for other services. 

The assistant in Senator Brown’s office reminded us that all Ohio psychologists and citizens can do their part to support changes in the ACA which includes the above mentioned benefits. To accomplish this purpose, she stated it would very helpful if everyone could take the time to do the following: 
  1. Contact your representative (Click here to find your representative.)
  2. Express your concern, particularly if you worried about individuals who may be negatively impacted if important benefits are cut.
  3. Most importantly: tell a story about someone you know who has been helped by the benefits extended by the ACA or who may be seriously harmed if these benefits are lost. The Senator’s assistant urged us to not underestimate the power of these stories.
I think we are at the crossroads of an important time in the evolution of our future healthcare system. We also live in a time when so many of us feel helpless when it comes to having an effect on forces which shape our professional lives. Right now before us is an opportunity to take a small action which could make a large impact. 

Jim Broyles, PhD
OPA Director of Professional Affairs

Tags:  ACA  Affordable Care Act Replacement  mental health parity 

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