The following three letters are an exchange of correspondence between Earle Silber, a member of The American from Chevy Chase, MD, and Dr. BJO, vice president of medical affairs of Xact Medicare Services. The letters, though abridged, contain the essence of the matter.
August 28, 1995
Xact Medicare Services
Dear Dr. Silber:
The Health Care Financing Administration has implemented a program called Focused Medical Review (FMR). Under this program, Medicare Part B carriers perform analyses of the claims data processed within its jurisdictions and compare it to data tabulated nationally for the same services…. The results of this FMR effort are communicated via publications to the provider community or to specific providers who have been identified in the analyses. The goal of FMR is to shift the focus of medical review from simple claims denials to an educational program on Medicares policies and procedures.
Xact Medicare Services recently analyzed claims reporting procedure code 90844, “individual medical psychotherapy by a physician, with continuing medical diagnostic evaluation, and drug management or supportive psychotherapy; approximately 45 to 50 minutes.” You have been identified as exceeding your peers in the utilization and payment of this code.
As required by Section 7504.3 of the Medicare Carrier's Manual, we are providing the enclosed illustration of your reporting pattern relative to this procedure code because you exceed peer norms. We urge you to review this report, making an effort to determine why your utilization differs from your peers (the peer group is defined as all physicians in your specialty and locality).
Since your utilization differs significantly from that of your peer group, we urge you to evaluate why these differences exist and take action, as appropriate, to realign your practice with that of your peer group.
We would like to advise you that your billing statistics will be reexamined in the future to evaluate the effectiveness of this educational contact. The carrier reserves the right to review claims submitted prior to the date of this notice if the reevaluation indicates that a provider may be inappropriately billing procedures for payment.
This reevaluation may result in a comprehensive medical review being initiated. In the event that your clinical documentation does not substantiate these services an overpayment will be pursued.
Please be advised if the misrepresentation of services on Medicare claim forms occurs, it is in violation of Medicare regulations. Anyone who submits a false claim to the Medicare program may be subject to criminal, civil, or administrative claims to the Government. Penalties can include imprisonment, criminal fines, civil damages and forfeitures, civil monetary penalties, and exclusion from Medicare and the State health care programs.
The aforementioned billing information will help you to independently assess the appropriateness of your claims reporting. Please ensure when billing for services provided to Medicare beneficiaries that you document the medical records accordingly.
Sincerely, BJO, M.D.
Vice President
Medical Affairs
September 18, 1995
Dear Dr. BJO:
I am responding to your letter dated August 28, 1995, in which you informed me that the frequency of my utilization of procedure code 90844 exceeds that of my peers. 1 was urged to review your report “to evaluate why these differences exist and take action, as appropriate, to realign your practice with that of your peer group.” The graph which accompanied your letter indicated that the average utilization of procedure 90844 is one thousand per hundred Medicare patients. This means that any more than 10 psychotherapy sessions per year for an individual patient would exceed the “peer norms.”
The comparisons made about my practice are not, in fact, comparisons with my peers and are therefore misleading. In addition to my training and certification as a psychiatrist, I also received additional training as a psychoanalyst and am certified by the American Psychoanalytic Association. I am known to my colleagues in the mental health professions as a specialist in providing these services, and therefore patients who are referred to me are those who require these particular treatment modalities. For this reason, my practice is not one of general psychiatry, to which mine is being erroneously compared.
At the present time, I am treating only one Medicare patient, and the pattern of my treatment of this patient does not differ from that of my practice with other patients. All of my patients are seen either in psychoanalysis or individual psychotherapy for fifty-minute sessions. At a minimum, I usually see patients once a week and for varying durations of time, sometimes briefly but more frequently over extended periods of time. Insight-oriented psychotherapy by its nature requires more frequent and extended treatment, which may require years.
The best model of care is one that considers the best form of treatment based on an evaluation of each individual patient.
…. To use an “average” number of visits, based on disparate modes of therapy, to compare number of visits appropriate for patients being seen in psychotherapy, is misleading and not consistent with good medical practice.
Your letter raises serious issues about the nature of services which Medicare intends to provide. If psychiatrists who provide psychotherapy were to keep their practice at the average level of utilization referred to in your letter, patients would not be seen for more than ten sessions per year. In effect, this would mean that Medicare patients would be denied access to either insight-oriented or supportive therapy, which may be indicated by the nature of their presenting symptoms and underlying problems.
As in my case, even one patient seen by a psychiatrist in psychotherapy once a week for approximately forty sessions per year would elevate that psychiatrist's practice above the level cited in your letter. In effect, this would result in a form of discrimination against Medicare patients, who would be denied an opportunity for insight-oriented or supportive psychotherapy (alternatives subsumed under procedure code 90844). I consider this to be the very serious and grave policy implications of your letter.
Sincerely yours,
Earle Silber, M.D.
Xact Medicare Services
Dear Dr. Silber:
Thank you for your correspondence dated September 18, 1995. The information you provided regarding your Medicare practice is helpful in evaluating your utilization and payment of procedure code 90844.
Your letter questions the nature of services which Medicare intends to provide. Please be assured that Medicare has no intention of denying beneficiaries access [to] necessary psychiatric services. We will continue to compensate you for psychiatric services which are medically necessary and appropriately documented.
Our previous correspondence urged you to evaluate your practice and take action, as appropriate, to realign your practice with that of your peer group. We appreciate that you have taken the time to evaluate your practice and found that your use of this procedure is appropriate for your patient's presenting symptoms and underlying problems. Therefore, please document your records accordingly and continue to submit claims to Medicare for reimbursement.
Sincerely, BJO, M.D.
Vice President
Medical Affairs