Insurance Update

Communications from Anthem Blue Cross, EquiClaim and Inovolan Regarding Billing Practices and Risk Adjustment Audits

September, 2016

In July, CAMFT sent a letter to Anthem Blue Cross on behalf of members who are contracted with the insurance company to provide behavioral health services. The purpose of the correspondence was to discuss the letters members have received from Equiclaim regarding their billing practices as well as requests from Inovalon for copies of provider's outpatient psychotherapy records. Anthem Blue Cross provided the following responses to CAMFT's concerns:

 "There are many forms of psychotherapy and Anthem Blue Cross encourages providers to use evidence-based treatment to meet the needs of our members. Regardless of the type of therapy provided, the CPT code billed must be consistent with the time spent providing the service and we want to ensure that provider documentation supports the time spent with the member. That being said, we leave decisions about what type of therapy, the length of the sessions, and the intensity of the services, to the provider to decide." In August, Anthem reported having made changes to its provider request process to include information about the requirements of California Civil Code Section 56.104 (which is the law CAMFT had asserted in the correspondence). As the result of a recent telephone conference with Anthem's Behavioral Health Director for the West Region, the Managing Medical Director for Behavioral Health Services West Region, the Business Change Manager within Anthem's Provider Audit Department, as well as representatives from Inovalan, CAMFT has learned Anthem is requesting information from clients' records to determine whether there may be additional health conditions pertaining to clients' overall health that have not been reported and to ensure that the CPT codes being billed are consistent with the treatment being provided. Request for information from Inovalan, on behalf of Anthem are for the purpose of conducting a risk-adjustment audit, which is a requirement imposed on specific insurance companies under the Affordable Care Act. According to these Anthem representatives, the following information is being sought for services rendered to clients during the current calendar year: Dates of services; Therapy start and stop times; Diagnosis; Treatment plan; and Progress to date. Prior to releasing information from a patient’s outpatient psychotherapy record, California psychotherapists should be cognizant of the requirements stated in Section 56.104 of the Civil Code. For more information about this law and options for responding to records from insurance companies, see Michael Griffin’s article “Therapists as Diplomatic Gatekeepers ”. 

Requests for information vary, and it is not possible to say what information should be provided in every case. It is recommended for a provider to promptly respond to the carrier’s request, to clarify the nature and the purpose of the information being requested, and to request the information that is required by California law. It is also ordinarily prudent for a therapist to discuss any request for information with the patient and to ask for his or her opinion or preference. CAMFT will continue to work with Anthem to ensure requests for information and records are made in accordance with applicable state and federal laws. The Insurance Update in the upcoming November/December issue of The Therapist will include a more detailed look at this matter.