APAPO presses Anthem about Inovalon audit

APAPO and the California Psychological Association (CPA) have suggested that members hold off on responding to the audit requests until we have more information.

Update (March 25, 2015): Since the time of this article's original publication, Anthem and APAPO have worked collaboratively to resolve the concerns APAPO and CPA raised in the Sept. 5 letter. Anthem agreed to notify patients of these audits as provided under California law. Anthem also agreed to let psychologists extract information from combined records to satisfy the minimum necessary rule under HIPAA. For more information, please see Update on Inovalon risk adjustment audits of practitioners.


The APA Practice Organization (APAPO) has heard concerns from psychology leaders and other psychologists in several states, including California, Georgia and Connecticut, about Anthem BCBS and its contractor Inovalon sending psychologists audit requests for patient charts. These requests state that Anthem needs this information to satisfy Affordable Care Act (ACA) data requirements.

Based on our concerns outlined below, APAPO and the California Psychological Association (CPA) have suggested that members hold off on responding to the audit requests until we have more information. We have also advised Anthem of this recommendation to members.

On Sept. 5, 2014, APAPO and CPA sent Anthem a joint letter (PDF, 104KB) expressing concerns about complying with the Health Insurance Portability and Accountability Act (HIPAA) minimum necessary rule and state law. The main concern is the organizations believe that they need to better understand what information Anthem legitimately needs under the ACA so that psychologists do not have to produce more than the minimum necessary information.

Anthem's form letter states vaguely that the request is to meet data requirements for Qualified Health Plans. Inovalon's form letter indicates that the documentation is necessary to "clarify specific member medical conditions." The joint APAPO/CPA letter asks Anthem to specify which of the various data requirements under the ACA drive its audit requests and to specify what information it really needs to respond to those requirements. APAPO and CPA expect that when these questions are answered, they will be able to suggest an appropriate minimum level of information that will allow Anthem to meet its ACA reporting obligations while respecting patient privacy in accordance with the "minimum necessary" rule under the HIPAA Privacy Rule (PDF, 1.52MB).

The letter also raises concerns under California and other states' confidentiality laws.

In initial communications with Anthem prior to sending the letter, APAPO has confirmed that Anthem is not expecting psychologists to produce psychotherapy notes in response to the audit request, and that Anthem will make that clear in future communications about the audit. Anthem has also expressed an interest in a dialogue about these issues and appears to be willing to work collaboratively with APAPO and CPA to resolve these issues.

APAPO has just learned of additional Anthem audit and refund requests:

  1. Correct Current Procedural Terminology (CPT®) coding audits by Sante Analytics regarding testing in Ohio.
  2. Refund requests by Anthem Healthkeepers Plus (Anthem's Medicaid HMO in Virginia) based on Anthem's unintentional overpayments.

We will be working on these issues with the affected state psychological associations and will keep members updated through future issues of this PracticeUpdate newsletter.

In the meantime, if APAPO members have questions or concerns, they can contact our Office of Legal and Regulatory Affairsvia email or call (202) 336-5886.

Current Procedural Terminology (CPT®) copyright 2013 American Medical Association. All rights reserved.