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Insurance Audits: OPA can help!

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Monday, March 27, 2017

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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