From July 1, 2015, through June 30, 2017, Medicare paid about $1.9 billion for psychotherapy services nationwide. That’s a lot of money. And, given that prior reviews by the OIG found Medicare had made millions in improper payments for psychotherapy services, it’s no surprise that the OIG’s recently audited a psychotherapy provider. The report of those findings, which was recently made public, was enlightening.
After analyzing Medicare claims data, the OIG selected Oceanside Medical Group (Oceanside) for their audit. Oceanside provides services at various facilities, including hospitals, skilled nursing facilities, and residential care facilities. For the audit period in question, Medicare paid Oceanside nearly $7 million for E&M services, psychotherapy, and psychiatric diagnostic evaluations provided by its owner, a licensed psychiatrist, and seven independent contractors which included three clinical psychologists, three nurse practitioners, and one physician assistant.
The OIG’s analysis of Medicare claims data showed that 39 percent of the Medicare payments that Oceanside received were for psychotherapy. The majority of these payments were for the two CPT codes representing 30 minutes of time spent on psychotherapy (with and without E&M). OIG’s objective was to determine whether Oceanside complied with Medicare requirements when billing for psychotherapy services.
The OIG reviewed a sample of 103 individual psychotherapy services:
- 51 services for 30 minutes of psychotherapy with an E&M service
- 43 services for 30 minutes of psychotherapy
- 9 services for 45 minutes of psychotherapy
The OIG then reviewed the documentation to determine whether Oceanside complied with Medicare requirements for billing psychotherapy services. However, it should be noted that the OIG did not determine whether these services were medically necessary.
According to the OIG, Oceanside did NOT comply with Medicare requirements when billing for psychotherapy services. In fact, they found that not one of the 103 psychotherapy services complied with the requirements.
- For 52 of the services, psychotherapy was not provided
- For 49 of the services, psychotherapy time was not documented
- For 2 of the services, adequate supporting documentation was not provided
As a result, Oceanside received $5,317 in unallowable Medicare payments. On the basis of the sample results, OIG estimated that Oceanside received at least $2.6 million in unallowable Medicare payments for psychotherapy services for the audit period. These overpayments occurred because Oceanside did not have policies and procedures or effective management oversight ensuring psychotherapy services billed to Medicare were actually provided, adequately documented, and correctly billed.
Example of Psychotherapy Service That Was Not Provided:
On August 14, 2015, Oceanside billed Medicare for a 30-minute psychotherapy service in conjunction with an E&M service. Medicare paid Oceanside $53 for the psychotherapy service and $32 for the E&M service. However, the medical record for the date of service did not indicate that psychotherapy had been provided. The medical record stated that the beneficiary had a urinary tract infection and would be treated with psychotropic medications to prevent any further decline in the beneficiary’s cognition.
Example of Psychotherapy Time That Was Not Documented:
On April 30, 2016, Oceanside billed Medicare for a 30-minute psychotherapy service for which Medicare paid Oceanside $53. For this service, the medical record did not include the time spent with the beneficiary to support that the provider had spent from 16 to 37 minutes with the beneficiary.
Example of Inadequate Supporting Documentation:
On October 15, 2016, Oceanside billed Medicare for a 30-minute psychotherapy service in conjunction with an E&M service. Medicare paid Oceanside $45 for the psychotherapy service and $28 for the E&M service. Oceanside could not provide the OIG with the medical record for the service. However, the OIG obtained the medical record from the facility where the psychotherapy service was furnished and found the nurse practitioner from Oceanside had created the medical record entry for the service on February 6, 2018. This medical record entry was created after the OIG had requested the medical record from Oceanside, and nearly 16 months after the date of service.
It should be noted that Oceanside did not agree with all of the OIG’s findings and recommendations. The full report shares some of the back and forth comments between the OIG and Oceanside, and is an interesting read. If your organization is involved in psychotherapy services, this report is a must read. It would also be wise to proactively audit your own claims to ensure psychotherapy services were provided, documented, and supported.