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APAPO Survey on the valuation of CPT codes

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Wednesday, May 24, 2017

You may be receiving a very important survey soon from the American Psychological Association Practice Organization. The surveys will be emailed to APAPO members, and will be gathering vital information regarding the valuation of Current Procedural Terminology (CPT) codes commonly used by psychologists, which directly affects reimbursement rates set by all insurance companies. The survey is developed by the American Medical Association /Specialty Society Relative Value Scale Update Committee (RUC). Click here to view an article from a recent APAPO Practice Update which explains the survey. It is very important for you, if you are a member of APAPO, to be on the lookout for the survey and to set aside the 2 hours it may take to complete it. If you have questions feel free to contact me.

On a related note, I received many positive comments about my last communication with OPA members regarding the letters from Change Healthcare. This group contacted psychologists regarding their billing practices and use of certain CPT codes. In that communication, I outlined concerns expressed by APAPO and OPA to Change, as well as gave specific recommendations on how to respond to their requests. During our recent OPA Convention and through email, many of you pointed out how helpful this information was. I feel compelled in response to point out to everyone that the guidance from that communication would have been impossible if not for the considerable efforts of APAPO’s office of Legal and Regulatory Affairs, specifically attorneys Alan Nessman and Connie Galietti. Both expended considerable time and effort communicating with the organizations in question, drawing on their considerable legal experience and expertise, to produce the guidance you received. This is only a small example of the ongoing advocacy and support Ohio psychologists receive from APAPO. Many psychologists today remain unaware of the vital support they receive from APAPO, and how our more local advocacy efforts are dependent on their help. I urge all Ohio psychologists to be mindful of this when making a decision on whether to become a member of this organization.

Tags:  apapo  cpt codes  survey 

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Can Psychologists Continue to Bill Medical Mutual 90837?

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Sunday, April 23, 2017

In March of this year, many psychologists in Ohio received letters from Change Healthcare, acting on behalf of insurance company Medical Mutual concerning the frequency of their use of CPT® code 90837 (psychotherapy, 53+ minutes with patient and/or family member) billed to Medical Mutual. These letters were addressed to psychologists allegedly using 90837 at a high rate compared to other Medical Mutual psychologists. Change Healthcare defines “high rate” as anyone using 90837s 70% of the time compared to 90834s or 90832s. Although these letters stated that they were for informational purposes only, some members read them as implying the possibility of onerous audits (and the possibility of refunds) unless the utilization of 90837 codes by the psychologists began to decrease. 

In the past, the Legal and Regulatory Affairs staff of the American Psychological Association’s Practice Organization (APAPO) has reached out to Change Healthcare to seek clarification of their intent in sending these letters in other states. During those discussions APAPO raised many issues about the letter. For example, APAPO staff noted that outpatient mental health practice lends itself more to the use of the longer 90837 code, while codes representing shorter time periods are more likely to occur in nursing homes or integrated care facilities. As a result, those psychologists who were allegedly high users of 90837 might not necessarily have been high users if they were compared to other psychologists in a typical outpatient practice. Furthermore, APAPO staff noted that the nature of these letters could give a chilling effect and dissuade psychologists from using the procedure codes most appropriate for their patients. 

Change Healthcare clarified for OPA and APAPO that the intent of these letters was truly to be educational (although we believe that this educational project was unnecessarily anxiety producing). Change Healthcare does not presume that a higher use of 90837 involves inappropriate billing. We learned that here will be no routine audit of those who use 90837 at a higher rate than other psychologists. Nor will Change Healthcare initiate any unusual efforts toward seeking refunds from psychologists who use the 90837 codes more frequently than others. 

Can Psychologists Continue to Bill Medical Mutual 90837?
Psychologists should continue to use their clinical judgment to determine the health care needs of their patients, including the length of a psychotherapy session. At this time, we are not aware of Change Healthcare limiting the use of 90837. We recommend that psychologists billing 90837 with Medical Mutual continue to use its billing guidelines as described in the next section. According to official guidance for CPT codes, 90834 (psychotherapy, 45 minutes with patient and/or family member) is to be used for sessions lasting 38-52 minutes. Code 90837 is to be used for sessions that are 53 minutes or more in duration. In addition, 

  • Psychotherapy times are for face-to-face services with the patient and/or family member.
  • The patient must be present for all or some of the service.
  • In reporting, choose the code closest to the actual time (i.e., 53 or more minutes for 90837).
  • Document start and end times.

Following this guidance should put psychologists in a good position if Change Healthcare later decides to review their records and/or practices. 

Finally, OPA members can contact me if their experiences with Highmark appear contrary to the guidelines described above.

Please note: Legal issues are complex and highly fact specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time and vary by jurisdiction. The information in this article does not constitute legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.

Current Procedural Terminology (CPT®) copyright 2015 American Medical Association. All rights reserved.

Tags:  Change Healtcare  cpt code 90837  Insurance audits 

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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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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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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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