Scully and Muszynski wrote:
If a patient is being treated by a psychiatrist with both medication and psychotherapy, each time the patient is seen the psychiatrist would be monitoring the patient's medical condition and response to medication as well as drug-to-drug interactions and side effect issues that might affect patient compliance and the patient's overall mental status. It is also clear that this monitoring would not necessarily always be noted in the patient's records unless there was a change in status.
In other instances, auditors determined that documentation was insufficient for a 45- to 50-minute session but sufficient for a 25- to 30-minute session, and the payment code was downgraded accordingly.
In a second letter to NYSPA, dated Oct. 31, 2003, Scully and Muszynski wrote, "The length of the note documenting psychotherapy bears no relationship to the length of the therapy session. å It is spurious to assert that the length of the documentation somehow directly corresponds with the time spent in a therapy session."
The letter continued:
Generally accepted psychiatric practice requires that the psychotherapeutic intervention be documented for each psychotherapy session, i.e., was the therapy provided insight oriented, behavior modifying, or supportive in nature. The length of the session is indicated by the CPT code selected, not by the length of the note in the medical record.
Oxford used Audit Review Service for its investigation. The company describes its staff as investigation specialists in detecting mental health care provider fraud.
"Mental health care has a higher level of provider fraud and abuse than any other medical specialty," according to Audit Review's Web site <www.auditreview.com>. Charges for undelivered services, duplicate charges and coding abuses are committed by individual practitioners, clinics and hospitals, it asserts. "The attitude that such practices are commonplace and unchallenged has resulted in these methods becoming business as usual for many mental health practitioners." Audit Review Service is associated with the mental health care fraud division of David Morse & Associates, the largest independent adjusting firm in California, with locations across the country.
The choice of Audit Review Service was the result of due diligence, Oxford spokesperson Maria Gordon-Shydlo told PT.Confidentiality Concerns
Psychiatrists who refused to release records to Oxford's auditors without written authorization from each patient were pressured by the company. In one instance, Oxford filed a complaint with the New York State Department of Health against a psychiatrist for failing to provide records. The NYSPA succeeded in having the complaint removed and getting the Health Department to issue a letter to all managed care organizations reminding them of state laws covering confidentiality and the release of medical records.
In their Oct. 31, 2003, letter, Scully and Muszynski wrote:
We are also concerned that Oxford may be demanding to see psychotherapy notes maintained by psychiatrists who are 'covered entities' under the [Health Insurance Portability and Ac-countability Act of 1996] HIPAA Privacy Rule and who have separated their psychotherapy notes from the balance of the patient's medical records. å Separate psychotherapy notes may not be disclosed to health plans without specific HIPAA compliant patient authorization and health plans may not condition payment or eligibility on the patient's providing such authorization.
Oxford believes that the audit was conducted with the highest level of protection, Gordon-Shydlo said, and it asked providers to black out any sensitive information before handing over patient records.
In the weeks following Oxford's decision to drop the audit, Stein was intent on making sure that Oxford returned all patient records. "We didn't want those treatment records that people had delivered to Oxford and [Audit Review Service] to sit in a cabinet for 20 years," he said.
He also was focused on holding Oxford to its promise of sending refunds to those psychiatrists who made settlements. The psychiatrists who did settle generally had repaid Oxford $5,000 to $15,000.
Muszynski said that the APA welcomes the opportunity to engage in discussions with any managed care company about what constitutes reasonable guidelines for medical record documentation and about adhering to confidentiality issues. The APA has many templates available for developing guidelines, he said, and Oxford should be able to reach consensus with providers over guidelines within a relatively short amount of time.
As for psychiatrists with other health plans and in other parts of the country, Muszynski said, the lessons from the Oxford audit are that it is important to document sessions to the best of their ability and to know that the APA is available if they feel they are being unfairly challenged.