On Aug. 3, 2020, following several months of advocacy by APA Services, Inc., and the Iowa Psychological Association (IPA), insurance company Wellmark Blue Cross and Blue Shield of Iowa agreed to stop abusive audits on psychologists and withdraw hundreds of thousands of dollars in recoupment demands.
Last fall, several APA members contacted the APA Services Legal and Regulatory Affairs (LRA) staff about audits conducted by Wellmark and subsequent recoupment demands—one practice faced a demand over $100,000. The basis for the collections were 1) a strange interpretation that the 60-minute psychotherapy code is only appropriate for crises and a few other narrow circumstances, and 2) arbitrary, unexplained determinations that only a handful of sessions were medically necessary (e.g. five or 10 sessions)
APA Services and IPA explained to Wellmark (PDF, 265KB) that the reviewer in these cases used bizarre standards that providers had no knowledge of. Wellmark suspended the recoupment requests and conducted a second review using known standards.
Unfortunately, the second review was just as flawed and led to recoupment demands exactly or almost exactly matching the original demands—despite using a different standard. This time the reviewer penalized providers for alleged record-keeping deficiencies that were not outlined in the published documentation requirements.
APA Services filed a second complaint letter (PDF, 284KB), copying the relevant state and federal agencies, and demanded that the recoupment demands be immediately withdrawn.
After this significant advocacy effort, Wellmark ultimately withdrew its huge demands and promised to take a purely educational approach to record-keeping issues. This continues LRA’s perfect success record in challenging large, abusive audits, dating back to the Oxford audits in the New York City tri-state area in the mid-2000s.