Practice Management

Accountability in the Post-OTR World

By Susan Frager, LCSW

Over the last 18 months, major managed behavioral care organizations have moved in the direction of either eliminating or reducing the burden of Outpatient Treatment Reports (OTRs). This is a good thing…isn’t it?

Of course it is! Those reports, especially when they consisted of essays, were burdensome.

Every insurance patient, every four to 10 visits. What a pain. I remember having to review those essays, when employed by the corporate ancestor of Magellan Behavioral Health. Ninety-nine percent of them were appropriate to the patient’s presenting condition, and of acceptable duration of care, given the symptoms. What a waste of everyone’s time and money.

Insurance companies finally accepted what we clinicians knew all along, namely, that paying care management staff to review these essays was cost-prohibitive. And where some companies responded by doing away with OTRs altogether (Cigna, Aetna, many of the Blues), others (United, Magellan, ValueOptions) moved to checklist-style forms that could be scored by a computer programmed with pre-determined algorithms according to diagnosis and symptoms.

So does this mean we can all go back to the old way of treating clients without expecting any interference from managed care?

NO !!!! Make no mistake. There is still accountability in the post-OTR world.

Any time an insurer is involved, they have the right to demand substantiation of "medical necessity," either before or after paying the claim. That’s why clients sign a release of medical records, denoted by the “signature on file” or live signature in box 12 of the claim form, which reads “I authorize the release of any medical or other information necessary to process this claim.”

So how does accountability work now that OTRs are gone? Cases are identified either by claims audits (typically number of visits per diagnosis much greater than average), or by the screening algorithms for those companies that utilize checklist-style reports.

Audits and requests for additional information should be taken seriously; If an insurer determines that there was not sufficient “medical necessity” for treatment, they can and do take back the money they have paid. In the case of Medicare, they even extrapolate.

Here’s how extrapolation works: Medicare audits a sample percentage of all the claims paid during the audit period and then generalizes about the whole number. So if the audit period is 2004 and you had 100 claims, Medicare audits 5 percent, or five claims. If 40 percent of the 5 percent (i.e. two visits out of five) is then found to have been not medically necessary, Medicare will conclude that 40 percent of ALL 100 claims in 2004 were not medically necessary. They will then demand back 40 percent of the 100 claims paid during 2004, not just the two visits of the audit sample. It could add up to quite a lot of money.

So it’s often a shock when that letter or phone call arrives, telling you that in general, you are averaging a greater number of visits per diagnosis than your colleagues, or that a specific client has been seen x number of times and they want to know what’s up. How should we as clinicians respond?

The first and most important rule is: DON’T PANIC. Take a deep breath. Or several. After that, try to remind yourself that there is nothing whatever personal about this request for more information. It is truly no reflection on your skills as a clinician. Because therapy is so personal, this is, I know, harder than it sounds.

The next step will be to respond according to what is requested. If there is a specific case identified, you may wish to consult with a supervisor or colleague, for objective feedback. Ultimately, however, everything will hinge on how thorough your clinical documentation was. It really is a case of “if it isn’t documented, it didn’t happen.”

What should good clinical documentation consist of? From an insurer’s point of view, the most critical thing is evidence that you are treating the diagnosis that is reported on the claim form. That means you must document the presenting symptoms which support the DSM-IV (ICD-9) diagnosis. These should be listed, for each visit.

It is perfectly all right to buy a symptom checklist, or make one up yourself, to make note-taking faster. Along with symptoms, each session note should consist of the following: the remainder of the diagnosis (Axis 2-5), a description of the patient’s mental status, presenting problems, psychosocial stressors, treatment goals, progress towards goals (or lack thereof), medications, and interventions. Note that the intervention should correspond to the CPT code billed. For example, insurance companies will consider it to be misrepresentation, if not outright fraud, to see that “marital counseling” was an intervention on a visit that was billed as 90806 (individual therapy).

Most major insurances have websites where treatment record review checklists and tools can be downloaded. The forms are very similar to each other; Pick one and evaluate your treatment record format against it. When you make improvements, the requirements of one insurance company will most likely match or come close to the requirements of all of them.

It’s not even just insurance company audits that are of concern. This is an increasingly litigious society. If by some chance a patient files a malpractice suit, or makes a licensing board complaint, your documentation will also be scrutinized. Lawyers and courts will compare your clinical practices (and treatment records) to what appears to be the generally accepted standard among the majority of your professional peers. Because insurance is so prevalent, your treatment record documentation and even clinical practices could conceivably be held to the standards set by insurers – regardless of whether you have filed a claim.

I am often asked, “I practice psychodynamically, do I really have to do keep this kind of record?” Unfortunately, yes, if you submit insurance claims ‑ and remember, even if you don’t, your patients might be submitting claims themselves. Audits look for the presence or absence of the above documentation to determine whether treatment was “medically necessary.” I am of the belief that while specific interventions can be psychodynamic in nature, it is still possible to structure a treatment record to practice defensively; i.e. to ensure maximum protection in the event of audit, lawsuit, or license board complaint.

If clients are asymptomatic, or if treatment is wholly based on a V-code, then it’s probably best practice to find a way of paying for services that does not include insurance. The client may not like it, but the language of insurance policies which cover psychotherapy typically specify “medically necessary psychotherapy,” which refers back to the medical model of DSM diagnosis, symptoms, etc.

If your documentation can stand up against any insurer’s treatment record review form, you should be in good shape, even if your number of visits exceeds the average.

If the insurance company does not ask you to justify a specific case, but you get a general letter about your utilization, you might consider calling Provider Relations or Medical Management and asking who there has a clinical background, someone with whom you can talk about your specialties and why it might be that you use a greater number of visits than average.

Perhaps you treat borderline patients, for instance, or dissociative disorders. Or perhaps it is simply a circumstance where you have a low sample size, and one particular client with a severe mental illness is skewing the statistics. As we all know, statistics can be misleading. Referrals and continued network participation are determined, in part, on the basis of average number of visits, and also on compliance with clinical “medical necessity” audits, treatment record documentation, and/or outcomes measurements. For example, United announced in a memo dated May 9, 2007, that they are using their “Wellness Assessments” beginning July 1, 2007, as part of a tool to measure outcomes. They state, “Clinician participation rates in administering the Wellness Assessment are included in reviews of clinician performance.” OTRs may be a thing of the past, but accountability is here to stay.

Susan Frager, LCSW, is a nationally recognized managed care expert. To access the Billing Hotline or to suggest future newsletter column topics, call Susan at 636-464-8422, or email: susan@psychadminpartners.com. © Susan Frager 2007.