Legal Corner: Highmark letters to psychologists raise concerns and confusion

Highmark Blue Cross Blue Shield assures Practice Organization that recent letters about 90837 are educational with no financial consequences.

Members of the APA Practice Organization and the Pennsylvania Psychological Association (PPA) reported distressing language in a recent round of letters from Highmark Blue Cross Blue Shield (BCBS) about the frequency of their use of CPT® code 90837 (psychotherapy, 60 minutes with patient and/or family member). If you received a letter in the last few months, here’s what you need to know. 

Background of these letters

Highmark BCBS and several other insurance companies began sending these 90837 usage letters to psychologists early last year. In March 2016, the Practice Organization intervened and obtained assurance from these companies that the letters were intended to be educational in nature.

Purpose of the letters

The letters sent recently by Change Healthcare (Change) on behalf of Highmark BCBS were addressed to psychologists they identified as using 90837 significantly more often than other providers within the same specialty. The recent batch of letters, however, appeared to contradict the educational intent of the letters.

According to this correspondence, Highmark (through Change) has been scrutinizing the claims of certain psychologists identified as high utilizers of the code 90837, starting Sept. 10, 2017. The letters went on to state that psychologists who receive a “Coding Advisory Message” will have to review their medical records to confirm that their billing accurately reflected their services and that the services are adequately documented. The psychologists would then be required to resubmit claims that had been properly billed.

Practice Organization response

The Practice Organization and PPA sent a letter to Highmark about our concerns. In addition to voicing our alarm at the reverse in policy, we pressed them to explain which correct filed codes on the medical/surgical side Highmark was also requiring to be resubmitted, and further explain how this requirement was in keeping with Pennsylvania’s insurance laws regarding prompt payment of clean claims.

Highmark and Change requested a meeting with APAPO and PPA. During this meeting, the companies reaffirmed their prior stance that the letters were to be educational. They acknowledged the error of including in the letter to psychologists the whole section of the letter relating to resubmitting correct claims. They further assured us that corrective letters explaining the error (PDF, 99KB) will be sent to psychologists who received the first one.

Next steps

PPA, with guidance from the Practice Organization, will meet again with Highmark to discuss more appropriate methods to address fraud, waste and abuse issues in behavioral health. In addition, Highmark and PPA agreed to discuss how to facilitate the positive impacts of behavioral health interventions in controlling overall medical costs.

Contact your state psychological association and the Practice Organization if you experience actions by these two companies that are inconsistent with the explanations above.

Please note: Legal issues are complex and highly fact specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time and vary by jurisdiction. The information in this article does not constitute legal advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.