Sara Epstein, M.D., a psychiatrist in southern California, recently called
APA asking for help. Dr. Epstein had received a request for documentation from
the National Heritage Insurance Company (NHIC), the California Medicare
carrier. The request asked for psychotherapy notes "to justify the
frequency and continued treatment of the psychiatric condition for
After sending a letter of protest explaining she could not send the
psychotherapy notes without patient authorization, Dr. Epstein contacted APA's
Office of Healthcare Systems and Financing (OHSF). Ellen Jaffe, the Medicare
Part B specialist in OHSF, immediately got in touch with Bruce Quinn, M.D.,
the new medical director for NHIC Medicare in California.
Dr. Quinn responded via e-mail, saying that the documentation request
letters have recently been changed to conform to Health Insurance Portability
and Accountability Act (HIPAA) regulations. In his e-mail, he reported that he"
was appalled that the letter specifically requested `psychotherapy
notes,' which was a backward interpretation somewhere along the line of the
letter production. As promptly as possible we corrected the letter to conform
to HIPAA. Our guidance to review nurses, our corrected letter, and our
internal help screens for review nurses now conform explicitly and exactly to
the HIPAA guidance."
The same issue was raised when OHSF received word from the New York State
Psychiatric Association in late June that a New York psychiatrist who had a
claim reviewed under Medicare's Comprehensive Error Rate Testing (CERT)
program (Psychiatric News, July 16) received a denial for the two
sessions on the claim that CERT reviewed because she had failed to provide
psychotherapy notes to the CERT contractor.
OHSF immediately got in touch with its contact at the CERT contractor, Dr.
David Perez, to explain that under the privacy rule of HIPAA, psychotherapy
notes are not to be released without specific patient authorization, and they
are not to be part of standard claims reviews.
Dr. Perez explained that AdvanceMed, the CERT contractor, was following
directions it had received from the Centers for Medicare and Medicaid Services
(CMS) and recommended that Melanie Combs, director of CERT at CMS, be
Andrew Whitman, deputy director for regulatory affairs in APA's Department
of Government Relations, immediately contacted Ms. Combs on this issue and was
assured by her in telephone conversations that CMS would notify CERT
contractors about the regulations protecting the confidentiality of
psychotherapy notes and how those regulations allow only information from the
patient's medical record to be released to CERT contractors. Psychotherapy
notes are specifically defined under HIPAA. (See box below at left for the
elements that are included in the medical record and those that are considered
to be part of the psychotherapy notes.)
APA received written confirmation on September 1 that the CERT contractor
has been notified that these regulations must be considered when requesting
patient records for its audits.
If you encounter any issues like this in requests for patients' medical
records from insurers, please notify APA's Help Line by phone at (800)
343-4671 or by e-mail at