Behavioral health claims continue to be an area ripe for fraud, waste, and abuse (FWA) within the healthcare continuum—and health plans continue to see more of them. In a recent study by the American Psychological Association, 79% of surveyed psychologists reported an increase in the number of patients with anxiety disorders since the start of the COVID-19 pandemic. Despite small decreases in demand for anxiety and depression treatment compared with 2021, demand remained high for behavioral treatments generally, with continued increases in certain trauma- and stressor-related disorders observed.

Catching FWA within behavioral health claims can be challenging due to the nature of the services performed, since many treatments include talk therapy and other services that can be hard to quantify. However, the process can often start with something as simple as finding a suspicious code. This is exactly what happened for one Cotiviti client, leading to projected annual savings of approximately $115,000 from a single provider.

A suspicious claim

A large health plan using Cotiviti’s prepay Claim Pattern Review solution flagged a provider for suspicious billing. A licensed clinical social worker (LCSW) submitted a suspect number of claims for CPT 90837 (Psychotherapy, 60 Minutes with Patient), billing nearly fifteen more units per patient than their peers and receiving three times more payment than the peer average. The provider billed almost exclusively for the highest-level psychotherapy procedure code, with little variation to their billings or utilization of lower-level psychotherapy procedure codes. They also billed 40 dates of service with more than eight hours of individual psychotherapy services for a single health plan. The provider advertised they accept many other insurance carriers, including Medicare and Medicaid. 

A pattern emerges

Our special investigations unit (SIU) reviewed claims data for the provider’s 12-month billing history, which identified potential excessive services. The provider’s data indicated more than 40 dates of service for which the provider billed more than 8 hours of services—up to 14 hours per day—an extremely improbable scenario. The provider also billed many consecutive days in a row with no days off, including federally observed holidays such as Thanksgiving, Christmas, and New Year’s Day. Peer comparisons identified the provider as an outlier among peers for the suspect procedure code. The provider received three times more payment than the peer average. 

As a result of this analysis, the provider was placed on prepay review for the suspect procedure code and medical record requests were sent to the provider for these claims. The provider produced medical records for most claims, but failed to produce records for several of the requested dates of service. All reviewed claims were denied due to the documentation not meeting the specifications of the health plan’s policies, including:

• The signature of the clinician appeared to be a photocopied signature or stamp on progress notes and consents, making it unverifiable
• The provider’s Individualized Plan of Care (IPOC) goals were not measurable
• The patient/guardian’s signatures were unverifiable, as they appeared suspiciously close to the font, size, and style of the clinician's signature
• The provider’s documentation within the records was inconsistent

Review finds conflicting documentation

Upon closer examination of the medical records produced by the provider, our SIU noted several claim lines contained significant inconsistencies regarding the identity, age, gender, health history, or sexual orientation of the patient. This may indicate that the services were not provided as billed or that significant cloning of records was occurring. Inconsistencies within the medical records included mismatched patient labels, incongruent patient ages versus dates of birth, and improbable life experiences (such as a young child’s occupation being recorded as a warehouse worker).

Finally, our SIU identified numerous issues where the patient, parent, or guardian signature on initial consent forms was identical to the provider’s signature. The patient’s signature in the record would also occasionally look significantly different than their signatures on other dates of service.

The results

The projected 12-month savings of placing the provider on prepay review is $115,000. Cotiviti’s medical reviews and data analysis supported the case being referred to the health plan’s own SIU for further investigation.

“Flagging erroneous or inaccurate claims is the starting point to a deeper investigation, and in this case halted any potentially fraudulent activity from going any further,” said Erin Rutzler, Cotiviti’s vice president of FWA. “Our investigators used Cotiviti’s comprehensive FWA analytics to identify the suspicious pattern and ultimately report this provider.”