The American Psychoanalytic Association has become a force to reckon with in the national mental healthcare arena by setting uncompromising standards for privacy and confidentiality and by successfully advocating for the patients and practitioners of psychodynamic psychotherapy.
Prime among our efforts were lengthy negotiations that shifted Oxford Behavioral Health's concern about billing abuse and fraudulent claims to a commitment to protect patient confidentiality. Oxford's newly revised documentation standards policy now specifies the maximum amount of information that can be requested for routine claims review in a template that explicitly excludes psychotherapy notes and does not reveal the content of the patient's material.
The new documentation standards policy, which took effect on April 1, 2005, may serve as a national model for third party documentation standards. In a recent interview, Alan Muney, Oxford's medical director, said that his company has begun internal discussions with its nationwide parent company, United Healthcare, about expanding what Muney calls “a good pilot.” Discussions between Oxford and the American Psychoanalytic Association are now exploring how best to use the new policy proactively to inform and promote an ethics-based approach to documentation standards industrywide. “The American Psychoanalytic Association takes the position that observing ethical standards makes for good practice, good care, and good business,” said Association President Jon Meyer.
Negotiations were originally instigated by complaints about Oxford's retroactive audit of services, which involved the application of an “extrapolation” method to a small sample of patient records that failed to meet documentation standards for correctly coded claims, which resulted in the demand for repayment of reimbursements to Oxford. Repayment requests were reported to be quite substantial, amounting to tens of thousands of dollars in addition to legal fees.
Jay S. Kwawer, director of clinical education at the William Alanson White Institute, reports that he was asked for medical records for 29 patients, including psychotherapy notes for 106 sessions. The services that Oxford sought to audit dated as far back as 1996, six years earlier. “Despite the fact that I was never a contracted ‘network provider’ with Oxford,” Kwawer reported, “they felt entitled to impinge on my professional autonomy with increasingly threatening demands that individual session notes be provided to them, without ever providing signed authorizations from patients consenting to the release of this information.” In the face of Kwawer's unwillingness to compromise his ethical or legal professional obligations, Oxford repeatedly affirmed its entitlement to such records, insisting that all its insured patients automatically consented to the disclosure of such private information simply by visiting a doctor's office and seeking reimbursement for treatment.
Muney responded to the concerns of several professional organizations by convening meetings to work out an acceptable documentation standard that provided Oxford with information needed for claims review yet safeguarded patient confidentiality. Participating organizations included the American Psychoanalytic Association, the American Psychiatric Association, the New York State Psychiatric Association, the American Psychological Association, the New York Psychological Association, and the New York State Society for Clinical Social Work.
“When we undertook to review documentation,” Muney said, “we uncovered much disagreement among the professional organizations about what is appropriate documentation from a medical records point of view as well as from the confidentiality point of view.”
“Members of the contingent from the Association were experienced and knowledgeable about HIPAA (Health Insurance Portability and Accountability Act) and “minimum necessary standards” and were committed to articulating and representing the ethical obligations of practitioners to protect their patients' rights,” commented Meyer, who attended the Oxford meetings along with Jim Pyles, Bob Pyles, and Dean Stein, APsaA executive director.
Meyer was involved in many subsequent discussions and direct negotiations to refine Oxford's new documentation standards policy and create a template for routine claims review that excludes psychotherapy notes. “This was a model of how disputes between clinicians and insurers should be settled,” Meyer said. “I think this discussion with Oxford establishes a national paradigm for resolving issues between patients, clinicians, and insurers both in terms of process and in terms of an outcome that respects HIPAA protection of psychotherapy notes and the ethical standards of the Association.”
As a result of the negotiations, Oxford's revised documentation policy standard now specifies seven “data elements” that comprise “Basic Information” for “regular and routine healthcare operations”:
Patient name
Clinician name
Date of service
Diagnosis
Lynn Stormon, Ph.D., who is on the TAP editorial board, is a postdoctoral research fellow in the Department of Psychiatry at SUNY Upstate Medical University.
CPT code or description of service
Other session participants
Focus of psychotherapy session.
In addition, psychiatrists are required to supply a brief description of medical evaluation and medication management services. The policy explicitly states: “This policy does not replace professional standards of record keeping or the clinical record-keeping requirements of state licensure law, governmental agencies, or other third party payers.”
Oxford does not cover psychoanalysis or modified psychoanalysis under CPT code 90845. The new documentation standards pertain to charting and reporting psychotherapy only. Practitioners who did not meet Oxford's documentation standards may have been following the American Psychoanalytic Association's six practice guidelines, which pertain to psychoanalytic treatments coded under CPT code 90845. These guidelines help clinicians set up and safeguard the necessary conditions for effective psychoanalytic treatment and may be viewed in the Practice Bulletins posted on the Association's Web site at: .
Oxford's new documentation standards policy includes the following notewor thy points:
Information specified as required by the policy statement is the maximum that can be requested for regular and routine documentation review.
If further information is needed by Oxford, a separate and contemporaneously signed HIPAA-compliant authorization from the patient/subscriber must be sought by Oxford rather than placing the burden on the clinician to obtain consent, which would put the clinician between the insurer and the subscriber.
Information released for “regular and routine healthcare operations” should be maintained separately from psychotherapy notes so that, in conformance with HIPAA protections and the Association's practice guidelines, psychotherapy notes are explicitly excluded.
Clinical information only reports the clinician's actions, for example, “assessed psychosocial issues,” “prescribed medication,” or “updated mental status.” The content of the patient's material is not requested and need not be reported.
The template or “Psychotherapy Treatment Record” that was developed to conform to the new documentation standards policy is notable for its simplicity and is optional in filing claims.
“The successful conclusion of our negotiations with Oxford is a cause for celebration,” said Meyer. “It is the first time that psychoanalysts and psychodynamic psychotherapists have been represented in direct negotiations with an insurance carrier to preserve the patient's fundamental right to privacy and confidentiality and in so doing take a crucial step toward ethics-based treatment. Oxford, after having been a cause for much concern, now deserves enormous credit for their decision that ethics-based practice is good business practice.”