Do commercial insurers and Medicare require psychiatrists to complete treatment plans?

[geripsyched]

I apologize if this question has already been asked and answered, but I couldn't find much on a quick search of this forum or reddit. Do Medicare and commercial insurers require documented treatment plans (and, if so, does it matter if the patients sign them - I send it to them electronically, but not all of them sign it)? Are treatment plans considered the standard of care? I remember doing them all the time as a resident when I worked at a clinic that served a large population with Medicaid (it seems NYS OMH may require treatment plans) and this clinic was more highly regulated than private practices. For my private practice, treatment plants seems like a waste of time, particularly since I include a fairly detailed A/P for each of my notes that describes patient/treatment goals and regularly talk about goals with my patients. Another local psychiatrist who sees patients with commercial insurance doesn't complete treatment plans.

Per NYS OMH (Title: Section 404.7 - Treatment Planning | New York Codes, Rules and Regulations): "An integrated services provider offering behavioral health services shall provide patient-centered treatment planning for each patient as set forth in this section." Does a solo practitioner count as an integrated services provider? Perhaps this only applies to certain OMH-regulated clinics...

As always, appreciate any insight people may have on this. Thanks!

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[ObsequiousAplomb]

Pretty sure you answered your own question. Unless your private practice is an integrated behavioral health clinic, doesn't sound like it. But I've never practiced in NY so only know what you have said.

 

[allantois]

This sounds like a medicaid thing

 

[geripsyched]

I think you are probably right about this being a Medicaid thing... I checked with another local psychiatrist, and he said he never did treatment plans. That would be nice. Creating these, getting them signed, and then tracking when they need to be reviewed and updated would be a pain. I'll still probably update the header of my note section from "plan" to "treatment plan" because it is so easy to do. : ) Thank you!

 

[Sushirolls]

I also saw this with Tricare and its various flavors.
They wanted a separate form completed on their form to be filled out, which basically was a SOAP note, and wanted predictions of how many visits in the future... who can predict? some people need every 4 weeks, others go in remission and are seen every few months. Treatment courses vary.

They can FUN themselves, and why I won't take any tricare in my private practice. Not going to do Twice the work and for half the pay. Its a double cut.

I won't take medicaid because of the pages and pages of rules and regs, and trying to decipher as you are doing. Too complex. And if you try calling them up to get answers its like any other insurance company, a waste of time that goes in endless phone tree loops.

 

[randomdoc1]

Personal experience. My clinic has been audited after the claim volume grew, with a growing practice. I don't think we flagged anything to indicate anything sketchy was going on. insurances will spot check you. . But especially if you bill 90837s more or the add on psychotherapy codes---make sure you have the documentation to substantiate the medical necessity over a pure med check. They have the legal right to claw money back. For psychotherapy they want to see things like
-start and end time of session
-treatment goals
-progress or lack thereof towards goals. If there is lack of progress, what are you changing in the plan to pursue progress.
-current level of functioning
-modalities of therapy used
-why would you add in therapy instead of just focusing on an in and out med check? I see it this way, it's cheaper for them to do just an E&M code, so they want to see they are getting their money's worth if they are paying for the add on psychotherapy and documentation needs to show the patient needs it. Although we all know patients do better with a visit that is more collaborative and comprehensive.

Those are the main ones I can think of now. To be on the safe side, when we got audited, I had providers write a summary of the patient detailing their case, treatment plan, rationale for frequency of visits, why we needed add on psychotherapy or a 90837 versus 90834. We never got a claw back.

Since we've had two audits, we now just have an automated template built into every note.
Yes, commercial insurance does this as do Medicare and Medicaid.

 

[calvnandhobbs68]

Personal experience. My clinic has been audited after the claim volume grew, with a growing practice. I don't think we flagged anything to indicate anything sketchy was going on. insurances will spot check you. . But especially if you bill 90837s more or the add on psychotherapy codes---make sure you have the documentation to substantiate the medical necessity over a pure med check. They have the legal right to claw money back. For psychotherapy they want to see things like
-start and end time of session
-treatment goals
-progress or lack thereof towards goals. If there is lack of progress, what are you changing in the plan to pursue progress.
-current level of functioning
-modalities of therapy used
-why would you add in therapy instead of just focusing on an in and out med check? I see it this way, it's cheaper for them to do just an E&M code, so they want to see they are getting their money's worth if they are paying for the add on psychotherapy and documentation needs to show the patient needs it. Although we all know patients do better with a visit that is more collaborative and comprehensive.

Those are the main ones I can think of now. To be on the safe side, when we got audited, I had providers write a summary of the patient detailing their case, treatment plan, rationale for frequency of visits, why we needed add on psychotherapy or a 90837 versus 90834. We never got a claw back.

Since we've had two audits, we now just have an automated template built into every note.
Yes, commercial insurance does this as do Medicare and Medicaid.

I play their stupid games because I want to get paid but lets not pretend it's about insurers "getting their moneys worth" or "making sure the patient needs" some service. This crap is purely to try to deny as much stuff as possible so they can spin more money back to their shareholders. Just check off whatever checkboxes they want you to (that they won't actually tell you they want in detail until they do the audit or bury somewhere in 1000 pages of "provider guidelines").

 

[TexasPhysician]

I’ve never written one ever

 

[Sushirolls]

I play their stupid games because I want to get paid but lets not pretend it's about insurers "getting their moneys worth" or "making sure the patient needs" some service. This crap is purely to try to deny as much stuff as possible so they can spin more money back to their shareholders. Just check off whatever checkboxes they want you to (that they won't actually tell you they want in detail until they do the audit or bury somewhere in 1000 pages of "provider guidelines").

But conversely, the records I get from patients and their previous ARNPs and some MD/DOs they merely checked a box on their notes for 90833.
Barely a reference to the therapy, but definitely checked on every encounter.

 

[aim-agm]

Per NYS OMH (Title: Section 404.7 - Treatment Planning | New York Codes, Rules and Regulations): "An integrated services provider offering behavioral health services shall provide patient-centered treatment planning for each patient as set forth in this section." Does a solo practitioner count as an integrated services provider? Perhaps this only applies to certain OMH-regulated clinics...

When you are looking at law or regulation, always check the "Applicability" and "Definitions" sections of the chapter.

Title: Section 404.3 - Applicability | New York Codes, Rules and Regulations

regs.health.ny.gov

(a) The provisions of this Part shall apply to providers seeking approval to provide integrated care services at a single outpatient site (host site). This includes: (i) locations licensed under Article 28 of the Public Health Law as diagnostic and treatment centers, extension clinics as defined in paragraph (g) of section 401.1 of Title 10 and general hospital outpatient programs as defined by this Part, (ii) substance use disorder outpatient services certified under MHL Article 32, and (iii) clinic treatment programs licensed under MHL Article 31.

(b)The standards apply to providers certified or licensed by at least two of the said participating agencies or in the process of pursuing licensure or certification by the Department of Health, the Office of Mental Health, or the Office of Alcoholism and Substance Abuse Services.

Title: Section 404.4 - Definitions | New York Codes, Rules and Regulations

regs.health.ny.gov

(f) “Integrated care services” means the systematic coordination of evidence-based physical and behavioral health care in clinics licensed by one or more state licensing agencies in order to promote health and better outcomes, particularly for populations at risk.

(g) “Integrated services provider” means a provider holding multiple operating certificates or licenses to provide outpatient services, who has also been authorized by a commissioner of a state licensing agency to deliver identified integrated care services at a specific site in accordance with the provisions of this Part.

 

[sloh]

But conversely, the records I get from patients and their previous ARNPs and some MD/DOs they merely checked a box on their notes for 90833.
Barely a reference to the therapy, but definitely checked on every encounter.

How common is this?

 

[Sushirolls]

Probably the default.