Five Types of Psychotherapy Audits
Avoid Practice Nightmares
There are 5 types of psychotherapy audits.
Targeted probe and education (TPE)
Risk adjustment audits
Abuse & waste audits
Record keeping
Recovery audit
Targeted Probe and Education Audit (TPE)
Medicare Administrative Contractors (MACs) conduct Medicare TPE audits of psychotherapists billing practices, utilization rates, or potential claim error rates that vary from their peers. TPE audits are also used to intervene and influence psychotherapist billing for services that have high national rates. In psychotherapy, there is a growing practice by Healthplans to use what is sometimes referred to as 90837 Utilization Audit Letters.
90837 audits come as form letters. They are specific to a face-to-face CPT code for a psychotherapy session lasting 53 minutes or more. The letters are based on electronic utilization review. These letters are not informative or educational. They are intimidating, if not coercive, advising psychotherapists they are using 90837’s more than a reference group.
Documentation to justify a 90837 should include:
Appropriate diagnosis.
Appropriate problems and symptoms list.
A documented reason for the extended session code during those appointments.
A treatment plan which documents the medical necessity of services.
Additional information as required by payer policies regarding use of 90837’s.
Start and stop times. Or, the start time and the amount of time.
Risk Adjustment Audits
Risk Adjustment Audit
Risk Adjustment Audits are conducted annually and are required of commercial health plans by the Federal Department of Health and Human Services (HHS). Risk Adjustment Audits come in a letter usually from a contractor acting on behalf of a Healthplan under the authority of HHS. The audits are required by HHS to assess a risk pool of insurers. You will receive a request for records and may have up to 60 to 180 days to respond. Your records will be thoroughly audited, usually by a contracted auditor who works for the Healthplan. The audit will compare you to peers. And Healthplans will be compared to each other. It is not clear what penalty or retribution is possible if a psychotherapist does not comply. Risk Adjustment audits are required by Federal Law.
Abuse & Waste Audits
A reviewer, during an abuse audit, is examining a patient’s medical records and comparing those to the associated billing. The purpose is to look for waste, overcharging, or fraud. These audits are usually initiated based on information provided by 3rd party auditors, employees or patients. They focus on intentional, wrongful or improper use or destruction of state resources, or seriously improper practice that does not involve prosecutable fraud. Abuse can include excessive or improper use of an employee's or official's position in a manner other than its rightful, legal use.
Record Review Audits (record keeping)
An auditor, during a record review audit, examines patients’ medical records for completeness. The focus is on identifying records that are incomplete rather than on their quality. The auditor is not trained or tasked to audit for waste or abuse. At most, they are looking for patterns that may constitute negligent behavior. While negligent (incomplete record keeping) is technically fraud, the intentions of the record keeper define whether or not any identified negligence is a matter for civil or criminal prosecution. The review auditor sends their findings to a more senior auditor authorized to manage the findings.
Recovery Audit
Recovery Audit Contractors (RAC) are companies contracted by CMS to identify Medicare overpayments and underpayments and to return Medicare overpayments to the Medicare Trust Funds. RACs review claims submitted in an attempt to identify improper payments. Although tasked to identify both overpayments and underpayments, RACs are highly motivated to identify improper payments or overpayments, since RACs are compensated on a contingency-fee basis. RACs tend to be zealous and to identify overpayments far more frequently than underpayments.
Healthplans conduct some recovery audits but more often contract with RACs who conduct audits authorized by commercial contracts with Healthplans.
Commercial Healthplan (Private Payor) Audits
Psychotherapists may find themselves subject to third-party payer audits by commercial insurers. These audits are similar to those conducted by the Center for Medicare and Medicaid (CMS). The audit process will vary depending on the third-party payer. As is the case with most Medicare and Medicaid audits, providers likely will receive an initial notice from the payor, which may or may not be the Healthplan itself, requesting copies of certain medical records. Or there may be notification from the payer of its intention to come onsite. In many cases where an onsite audit is conducted, the auditors will hold entrance and exit interviews with provider staff. Onsite reviews may also be conducted by obtaining access to the providers electronic health record system if that is within the scope of the Healthplan’s contract with the psychotherapist.
For more information see:
https://www.mentorresearch.org/grid-charting-and-training