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CSWA - Treatment Reviews - 7-7-20

07 Jul 2020 11:25 PM | CSWA Administrator (Administrator)

I have heard from many members about letters that they have received from a number of insurers in what is being called a “treatment review”.  You will recall that these reviews were part of the process that was put in place when the Affordable Care Act went into effect in 2010.  The basis for these reviews was left up to the judgment of the insurers.  These reviews generally occur every two years.

The last time this came up was in 2018 when Global Tech mailed out 10,000 letters to Medicare LCSWs,  questioning their practice based on three areas: how often a patient was seen; how long a patient was seen; and whether the 90837 CPT code was used regularly.  We are being compared to all other LCSWs in the insurance plan and identified as being ‘outliers’ in one or more of these areas.  As with the last round of reviews, this process is flawed as it does not take into account the conditions being treated.

The current letters are being sent by a number of private insurers including Anthem, Carefirst, and OPTUM (UBH).  Some of the companies are separate entities, such as CIOX like Global Tech.  Some are directly from the insurer.  It is necessary to comply with these reviews to avoid being penalized. 

If you have received one of these letters and would like some citations to support  length and frequency of treatment, here are some examples:

  • Studies that support a ‘sleeper effect’ for long term psychodynamic therapy in which there continues to be a course of clinical improvement following termination of therapy (Abbass et al., 2006; Anderson & Lambert, 1995; de Maat et al., 2009; Leichsenring & Rabung, 2008; Leichsenring et al., 2004; Shedler, 2010).   
  • For patients with a broad range of physical illnesses, there is evidence that short term psychodynamic therapy decreases utilization of health care resources.  Abbass, Kesely, & Kroenke, (2009) did a meta-analysis of 23 studies involving 1,870 patients who suffered from a wide range of somatic conditions (e.g., dermatological, , neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, genitourinary, immunological) and found a reasonable effect size of .59 in diminishing the severity of their health disorders.  Shedler notes a similar robust finding stating “Among studies that reported data on health care utilization, 77.8% reported reductions in health care utilization that were due to psychodynamic therapy – a finding with potentially enormous implications for health care reform” (Shedler, 2010, p.101).
  • With respect to more chronic mental health conditions, Leichsenring (2008) comments in this study that a considerable proportion of patients with chronic mental disorders or personality disorders do not benefit from short-term psychotherapy.  This meta-analysis showed that LTPP was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning.  Furthermore, some cost-effectiveness studies suggest that LTPP may be a cost efficient treatment (Bateman, Fonagy, 2003; de Maat, Philipszoon, Schoevers, Deffer, de Jonghe, 2007).

Data on why it is necessary to use 90837 instead of 90834 is harder to come by, since there is only one minute difference between them.

While it is possible that there may be some audits after the treatment review, this affected a small number of LCSWs in 2018.  The treatment review itself is not an audit.

This process is a frustrating and anxiety-producing one, especially with the difficulties most of us have had moving to telemental health and dealing with the pandemic.  CSWA continues to work with CMS to accept the variations in practice without requiring these reviews.  It may require Congressional action as the ACA was approved by Congress.

Let us know if you have any other questions about this process.  Stay safe and healthy.

Laura Groshong, LICSW, Director, Policy and Practice

Clinical Social Work Association
The National Voice of Clinical Social Work

Strengthening IDENTITY | Preserving INTEGRITY | Advocating PARITY

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