Professional Practice: Hey folks. They’re Screwing Us Again

What can you do when the managed care company says they want to audit your records? If you have patients covered by Oxford Health Plan, they want to see all your records, not just the patients covered by them. Don’t cave in!!! Here’s what you do. Call the Practice Directorate and get first hand advice from Russ Newman, Ph.D., the Executive Director of the PD or from Alan Nessman on the legal staff. They are on top of the situation. That’s 1-800-374-2723. Next, call your state association executive director or director of Professional Affairs and get local advice. The states hit by the latest managed care onslaught are New York, New Jersey and Connecticut. These states are tracking the situation and are in touch with each other and the PD and our lawyers every step of the way. So folks don’t despair, if you’re one of those “assaulted” by the managed care company Oxford Health Plan.

One of our Western colleagues who is in a large group practice reported the following: The “auditors” walked into his office. He asked each of them what their credentials were. One was a nurse, one a business man, and one a clerk. He refused to let them see his records since none of them was a mental health credentialed person. Nor had his patients consented to let their records be reviewed. He wasn’t intimidated by them. Perhaps we can all go to school on his example and not be intimidated by the auditors. He wrote a letter to them (via his attorney) and asked how they were going to guarantee confidentiality once they took them off site. The group got a letter back saying at this time they weren’t going to audit the records but reserved the right to do so in the future. That was 5 years ago and no one has called since.

Russ Newman Ph.D., J.D. sent a letter to Oxford yesterday asking them to desist in their practices and implying that if they didn’t further steps would be taken. We’ll have to see what happens next.

This latest managed care abuse became public when the New York Times of September 27,2003 published the horror story. Oxford Health Plans, a managed care company, sent out audit notices to 300 psychiatrists, psychologists, and social workers (100 in each category) in the New York Metropolitan area. They followed this up with demands for payback of funds paid for services rendered since 1997 because the therapists notes were “inadequate”. Some of the payback demands were for as high as $149,000. The professionals involved were very upset and looking to our leadership for support and a plan that would protect them from this unprecedented harassing and absurd demand.

The professional organizations were contacted by the NY Times reporter and here is what some of them said. Seth Stein, Executive Director and general counsel of the New York State Psychiatric Association was quoted..:We’ve never seen that and to do it retroactively is absurd and unfair.”

Gayle Everitt, Executive Director of the New York State Psychological Association said,,”They’re just hitting people up for money. That’s all this is about.”

The situation in New Jersey is somewhat different from NY and Connecticut in that NJ is the only state in the country that has a peer review law which states that the patient’s confidentiality is protected and only bare minimal information (name rank and serial number sort of thing) is permissible to be sent out to third party payers. NJPA Director of Professional Affairs, Don Bernstein, Ph.D. has been intimately involved with the three known NJ therapists who received audit notices and has been in touch with the Board of Examiners who uphold the Peer Review Law as well as NJPA’s attorney. So far they are attempting to comply with the law and black out all personal information on their patient notes. If it is true that all Oxford wants to know is whether the sessions were held so that there is no fraud involved that information can be delivered to them with all personal info blacked out. The issue of fraud seems to this writer a red herring. I would grant you that there may be fraudulent practitioners but I suggest they are very rare. All who have been trained at Rutgers for example have been taught the code of ethics of APA and the therapists I have trained have never shown any tendencies of that kind. To go after 300 therapists with the idea of preventing fraud seems ludicrous to me. So what is this really about? Are they after fraudulent folks? Are they harassing us? Are they simply trying to regain money spent because they are financially hurting? I have no clue as to their motives. I only know that their approach is experienced as an attack on our profession and it angers me.

The Practice Directorate published a statement on the 42 Listserv which described the situation as it was unfolding and stated they had “serious concerns about the legality of this practice” and urged Psychologists involved to be in touch with them. They are looking into the matter and will be offering legal advice as they get deeper into the facts of the case.

The kicker in this fiasco concerns the question of “inadequate notes”. In some cases Oxford claims that the notes are brief and therefore are not indicative of a 45 or 50 minute session and should be billed as 90804 rather than 90806. Again this would then result in a refund of money by the psychologist. This is bizarre. Most therapists write brief reminders of the session and many don’t write much at all. There are no guidelines for notetaking and to describe the notes as inadequate is clearly a value judgement by a nonprofessional. Once again, this is how big business takes over a profession and creates criteria that suits them and not the patient who is working with the therapist. When business moves into the world of psychological treatment they look to the bottom line and not to what is helping the patient get better. The lack of trust between Oxford and its panel of therapists is very sad.

There is recklessness in the managed care industry. In Virginia, for instance, the Blues announced a 30% reduction in the fees psychologists could charge and this resulted in a mass exodus of many Virginia Psychologists from the managed care company. The company continued to advertise as though their panels were full. This practice has been called “Phantom Networks”. They were sued by the Virginia Psychologists with the support of the Practice Directorate and it was very successfully resolved. There are still some matters under appeal so the case isn’t fully settled. How many “Phantom networks” exist out there? This question needs to be researched and the Division 42 Task Force on Managed Care and Health Care Policy is planning to do just that.

This article was written to alert 42 members to another abuse by a managed care company. Hopefully, the matter will finally be settled in support of psychologists but meanwhile caveat emptor. Until we change the health care delivery system in America and take it out of the control of business for profit companies we are open to getting screwed again.

This article was written prior to a letter from Dr. Russ Newman to Oxford Health Company. The letter was a very strong condemnation of Oxford’s behavior in demanding payback of funds from 1997 to the present. One Psychologist I spoke with was asked for $150,000 to be paid back. The letter said if Oxford didn’t cease their practice consequences would follow(implying lawsuit). Oxford responded by stopping all requests for payback, stopping all “attacks” on therapist’s notes as though the amount of notes equaled the time spent with the patient, which is nonsense. They countered with an offer to meet with appropriate officials to discuss these matters and our folks are ready to meet with them. It looks like, with the help of the Practice Directorate, a crisis has been averted. However, vigilance is still required. Who knows where “they” will strike next.???

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