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Insurance Audits: How to be Prepared!

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Wednesday, April 12, 2017

I have spent considerable time in the last couple of years providing OPA members help and support with insurance issues. Often, concerns from psychologists arise when an insurance company questions individual psychologist’s billing or record keeping practices. When these questions are raised, psychologists often feel confused about whether, what kind, or how much information an insurance company may need, what they are entitled to, and how to provide this. This past month has been no exception to this ongoing need for clarification. Many who follow the listserv or read my emails know that Medical Mutual recently contacted several Ohio psychologists through an auditing company, Change HealthCare, to raise questions regarding billing codes used by psychologists. My experience with these issues continually leads me back to some basic suggestions for most of us who provide clinical services: a little bit of preparatory work can go a long way toward being ready for audits or other kinds of scrutiny from insurance companies. With this in mind, I would like to make the following suggestions:

  1. Make sure the initial consent document used in your practice includes language designed to provide consent for releasing patient information in response to a broad array of insurance company requests.

    For example:
    You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record.... By signing this Agreement, you agree that I can provide requested information to your carrier.

    This allows for the release of basic clinical information which may be required by the insurance company.

  2. HIPAA allows for psychotherapy notes to be kept separate from the rest of a client’s clinical record, and offers a greater level of protection for these notes.  I suggest psychologists maintain this separate record. This allows for less sensitive, more basic clinical information to be easily released in response to an insurance company audit while offering greater protection for client privacy.

  3. Most insurance companies require that we follow basic record keeping guidelines set primarily by Medicare. When billing time based CPT codes, the more general clinical record should include documentation which supports the procedure (separate from the psychotherapy note) for each session billed including:
  • Session start and stop time
  • Modality
  • Diagnosis
  • Symptoms
  • Functional Status
  • Focused Mental Status Exam
  • Treatment plan goal addressed, prognosis, and progress
  • Name, signature, and credentials of the person performing the service

Following these suggestions will help many psychologists to readily respond to most audits conducted by insurance companies for the variety of reasons that I am familiar. More detailed guidelines on record keeping will be provided during my workshop at OPA’s upcoming convention (Thursday, April 27 at 9:00 a.m.). I hope to see you there! 

Jim Broyles, PhD
OPA Director of Professional Affairs

Tags:  insurance  Insurance audits 

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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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