Dealing With Commercial Insurance Peer Reviews

Calls to APA’s Practice Management HelpLine indicate there has been an increase in both concurrent and retrospective reviews by commercial insurers of the combined E/M and psychotherapy care provided by psychiatrists, regardless of whether the psychiatrists are members of the insurers’ networks.

There are several important points to keep in mind if you are contacted for a review. First, be sure that you are given a written statement regarding the purpose of the review and issues to be covered. Second, since the focus of these reviews is invariably the medical necessity of the care, always ask to receive, and be prepared to understand, the precise guidelines the payer uses to determine the appropriateness of treatment. And, finally, remember to contact the HelpLine when you’ve been asked to do a review. APA has been tracking this kind of care management and is monitoring the reviews to determine whether they involve mental health parity issues and/or violations of the federal regulations governing claims denials.

Initially, you may be asked to participate in a phone call with one of the insurer’s reviewers. This reviewer is almost never a psychiatrist but is typically a social worker or counselor who has some familiarity with providing behavioral health care. The focus of this initial contact is often on the length of time the patient has been receiving the combined E/M and psychotherapy services, with the suggestion that if the patient’s condition has improved since treatment began and symptoms have abated, there may no longer be a necessity for continuing treatment.

The following vignette is an example of this type of call from an APA member:

During the initial phone call, the nonphysician reviewer referred to treatment guidelines and suggested the psychiatrist was not in sync with them. She noted that the psychiatrist had been seeing the patient for more than six months and that the patient was functioning better; she then explained that the company had patient education information available online that could provide the patient with the necessary ongoing support to cope with her depression and anxiety without the need for continued weekly treatment.

The psychiatrist did not agree with that conclusion and was then directed to schedule an appointment for a case review with one of the company’s staff psychiatrists.

At the beginning of the subsequent phone call, the psychiatrist took the advice of APA’s staff and asked to see the treatment guidelines referred to in the previous call so that she could better understand the basis for the insurer’s concerns about continued treatment. She emphasized that she would not talk to the peer reviewer until after she had reviewed the guidelines. The peer reviewer sent the guidelines to the psychiatrist along with a statement that another phone review would be scheduled.

The reason that APA staff had suggested she ask to see the guidelines is that insurers are required by federal law to provide the specific information on which a denial of care is based. This is necessary to ensure that behavioral health care is not subject to limitations that are different from those applied to other types of medical care.

The second peer review call occurred a week later. The insurance company’s treatment guidelines did not provide any definitive criteria about when therapy should be terminated. The psychiatrist maintained that, based on the patient’s symptoms and functionality, there was continuing medical necessity for weekly treatment. The peer reviewer asked for specifics from the patient’s life to support this, and the psychiatrist demurred, explaining that she could not provide that information because it was part of her psychotherapy notes (which are kept separate from patient medical records) and thus could not be released under HIPAA regulations. She instead cited the patient’s medical comorbidities and asserted the necessity for continued care. The peer reviewer then asked how long the psychiatrist projected the need for care to continue. The psychiatrist responded that she thought treatment would be necessary for at least another six months. In response, the peer reviewer authorized four more months of weekly care.

Here are the take-home messages from this encounter:

• If you know your patient’s care is medically necessary and stand your ground during a peer review, you will likely prevail.

• You need to document the psychotherapy you provide just as assiduously as you document E/M work if you want your treatment to stand up under a peer review or payment audit (see here). ■