In its recent audit report available here[1], the Department of Health and Human Services’ Office of Inspector General (“OIG”) determined that many psychotherapy claims from a sample set did not meet Medicare billing requirements to support reimbursement. The OIG found that out of 216 sampled enrollee days, 128 days contained documentation deficiencies, such as not including documentation of: start and stop times for sessions, treatment plans, psychotherapy services furnished, or criteria necessary to support “incident to” requirements. Based on these findings, the OIG estimated that $580 million out of $1 billion Medicare Part B payments from March 1, 2020, to February 28, 2021 were improper.
CMS agreed with many of OIG’s recommendations, specifically to:
(i) initiate the recoupment process through MACs for identified overpayments;
(ii) identify and notify suppliers with potential overpayments;
(iii) evaluate psychotherapy services with medical review contractors so that services are documented and billed in accordance with Medicare requirements; and
(iv) provide further education on proper billing to prevent improper Medicare payments.
The OIG’s audit findings will likely increase scrutiny of psychotherapy providers by Medicare and other payers in the years to come. The COVID-19 public health emergency coincided with a dramatic increase in the demand for mental health services, and the corresponding increase in claims raises concerns of potentially improper billing practices. Psychotherapy providers must be aware of the specific documentation requirements of the applicable payer, which, in the case of CMS, is the Medicare Administrative Contractor (“MAC”) assigned to the region.
In response to the OIG’s recommendation that CMS review the differing Local Coverage Determinations (“LCDs”) set forth by MACs for psychotherapy services, CMS asserted that there was no requirement for uniformity across all jurisdictions for LCDs. Nonetheless, CMS indicated that it will review documentation requirements for psychotherapy services as currently provided in LCDs, and may require updates to the criteria impacting coverage.
How Frier Levitt Can Help
Frier Levitt attorneys regularly counsel clients who are subject to CMS investigations and audits, as well as clients who are proactively seeking to ensure compliance with the coverage rules of CMS and other payers. If you receive an audit letter or would like to conduct a self-audit to ensure compliance with Medicare billing rules, call Frier Levitt to speak with an attorney.
[1] Insert hyperlink to https://oig.hhs.gov/oas/reports/region9/92103021.asp
