Psychologists who often provide additional and longer psychotherapy sessions to Medicare beneficiaries, particularly those with complex cases, are considering opting out of the program to avoid being unfairly audited by the Centers for Medicare and Medicaid Services (CMS). In response, APA has called on CMS to change the way it conducts audits and reviews psychologists’ Medicare claims to preserve patients’ access to mental health treatments.
“As the Medicare population grows more beneficiaries will need access to psychologist services. It is critical that the CMS take steps now to ensure that there will be enough psychologists in the program to meet the demand,” APA said in a letter (PDF, 98KB)opens in new window sent May 13 to CMS Administrator Seema Verma.
Practitioners told APA that they received letters from a contractor working with CMS containing a comparative billing report (CBR). The CBRs compared the psychologists’ Medicare billing and service patterns to the averages for psychologists regionally and nationwide, noting that psychologists in Medicare were providing more psychological services to beneficiaries than other mental health professionals in the program.
APA found, however, that the CBRs analyzed only the total number of Medicare claims submitted by providers and did not consider additional key pieces of information, such as the number of beneficiaries the psychologist treats or whether certain conditions required additional psychological services.
Psychologists also told APA that pre-payment audits — where CMS withholds provider reimbursement for all Medicare claims until completion of a full audit — place a significant burden on their practices and serve as another reason to opt out of Medicare.
To protect beneficiaries’ access to psychologists and encourage psychologists to remain as Medicare providers, APA asked CMS to consider the following changes to its claims review and audit policy:
- Require that a psychologist — not another type provider — review claims data for a psychologist’s services.
- Consider additional information when reviewing claims data, such as the size and nature of the practice, treatment modalities, location and the types of patients seen.
- State explicitly in letters informing psychologists they are under review for a potential audit what the concern is and what information the agency needs to resolve that concern.
- Require that Medicare administrative contractors explain in local coverage determinations what kinds of documentation the treating psychologist should provide to justify medical necessity for a treatment or service.
- Perform prepayment audits only in cases where there is a reasonable belief that fraud or abuse is involved.
In the letter to CMS, APA emphasized that the organization wants to continue working with the agency to ensure that methods for detecting fraud do not “drive psychologists out of Medicare.”
If you have questions about Medicare’s reimbursement policies for psychological services, please visit APA Services. You can also send an email to APA Advocacy staff or call (202) 336-5889.