Communications from Anthem Blue Cross, EquiClaim and Inovolan
Beginning in approximately August, 2015, numerous providers received correspondence from Anthem, stating, among other things, that their use of one or more psychotherapy service ("CPT") codes “appeared to fall outside of the average utilization” for their specialty. These letters, and in some cases, related requests from Anthem for copies of patients’ mental health records, have generated considerable confusion and concern among providers. In letters to providers, Anthem explained that the purpose of their communication was "educational," to "ensure proper coding and payment of claims." Many of our members questioned whether such language reflected the true intent of Anthem in contacting therapists. Furthermore, the language utilized in some of Anthem's correspondence struck many providers as unnecessarily threatening in tone, stating, for example, that the provider may be subject to post-payment and/or pre-payment records reviews, by Anthem's "Provider Billing Integrity (PBI) Team.” Many providers have also received letters and phone calls from Inovalon, on behalf of Anthem, requesting entire copies of outpatient psychotherapy records for the purpose of fulfilling federal mandates related to the Affordable Care Act.
CAMFT staff has been in communication with Anthem’s representatives on this matter, but the responses and information received have not been sufficient to address our concerns. CAMFT is in the process of drafting a formal letter of concern to Anthem’s Director of Behavioral Health Services and will keep members apprised.
CAMFT Staff Attorney, Michael Griffin, JD, has written an article discussing how a provider may consider responding to these requests, "Therapistsas Diplomatic Gatekeepers: Responding to Record Requests for Risk-AdjustmentAudits".