As a mental health counselor, Sarah Alexander spends her days hearing from clients about trauma, depression and related topics. But, she said, what keeps her up at night is the constant "axe over my head” of an insurance company audit potentially demanding hefty sums over claimed discrepancies.
Alexander, who practices in Portland, is among the counselors and therapists supporting House Bill 2029, which would establish strict requirements on how commercial health insurance companies, the Oregon Health Authority and its care contractors audit claims for payment made by behavioral health providers.
Supporters of the bill say the audits can be triggered by minor paperwork errors and can lead to having to repay tens of thousands of dollars long after the claims were paid. Some, like Alexander, say the threat of audit has them contemplating leaving the profession. Others might no longer accept insurance —despite the state’s shortage of behavioral health providers.
“This is about protecting therapists in our state, and it’s about access to care,” Tiffany Ketterman, a licensed counselor and director of the Oregon Mental Health Providers PAC, told The Lund Report.
But lobbyists for insurance companies and their counterparts who oversee the Oregon Health Plan say the bill’s requirements would be unworkable, add to costs, and could put insurers in the position of violating federal law and existing state regulations.
If the law passes, “we will have two different standards for behavioral health providers and for physical health providers. This will be administratively burdensome for providers who provide care in both settings,” Rick Blackwell, lobbyist for PacificSource Health Plans, testified to the Oregon House Behavioral Health and Health Care Committee last month.
PacificSource oversees coverage for the Medicaid-funded Oregon Health Plan in many parts of the state, as well as for Medicare and commercial health insurance. Rules governing the three coverage areas already have different sets of requirements — to which the new bill would add conflicting ones, Blackwell argued.
The bill would prohibit insurers and the state from demanding repayments from behavioral health providers over minor paperwork errors. It would also limit how far back demands for repayment could go. It would also require “plain language” explanations of how behavioral health providers can resolve claims and give them a chance to fix errors found in an audit.
The bill is similar to one proposed two years ago. State Rep. Rob Nosse, who sponsored both bills and chairs the House health committee, told The Lund Report he’s not sure why the earlier version didn’t pass despite its bipartisan support.
The bill is scheduled for a vote in Nosse’s committee on April 8.
The Oregon Health Authority, which audits Oregon Health Plan provider reimbursements in keeping with federal requirements, was not able to immediately comment on the bill.
Imbalance of power
Ketterman, who owns a group practice, said she was audited for the first time around 2013 when she was in her first year of practicing. She said an administrator from a coordinated care organization, a regional Medicaid insurer, handed her a huge binder of administrative rules and told her to “figure it out.”
Nearly a decade later, while working in a group practice, the Oregon Health Authority demanded she pay back $19,000 for services she performed years before, Ketterman said. But, she said, the agency was citing the wrong set of administrative rules. She went through documents “line by line” to challenge the audit, and ended up having to pay back about $10,000.
Other mental health professionals told similar stories in testimony, some saying insurers demanded they pay back tens of thousands of dollars promptly after an audit.
Henrietta Knox, a counselor in Harrisburg, told lawmakers during a hearing last month that a coordinated care organization found 88 errors in her group practice’s charts that represented about $13,000 in improper payments. But she said auditors extrapolated the sample to demand a quarter million dollars, which she said was later reduced.
J.L. Wilson, a lobbyist for Oregon Independent Mental Health Professionals, told lawmakers that most practices don’t have the resources to challenge inaccuracies in health insurance company audits, adding that “The balance of power is tilted so heavily. Insurance companies have the lawyers, claims, reviewers, policies and procedures designed to constrain payments.”
Audits would be limited in scope, number
Among other things, the bill would require that audits be reviewed by a behavioral health professional. Not only that, but insurers and the government can only demand repayments for identified errors, as opposed to demanding sums estimated from reviewing a limited sample of claims.
Insurers and state officials would also be banned from conducting multiple audits of a behavioral health provider at the same time. They also could not pay auditors based on the number of mistakes they find.
The health authority would be required to set up a unit to develop materials that would educate providers explaining the documentation that is necessary for audits and the best practices to prepare for them.
Anti-fraud efforts would be hurt, insurers say
During a hearing last month, lobbyists for insurers said the bill would be difficult if not impossible to implement.
Blackwell, the PacificSource lobbyist, told lawmakers that the federal government already has rules that require insurers to follow certain procedures aimed at addressing fraud, waste and abuse. He also said that PacificSource makes information on fraud available to providers in a handbook online that he was able to find within three clicks.
Mary Anne Cooper, director of government relations for Regence BlueCross BlueShield of Oregon, expressed similar concerns, saying the bill conflicts with federal requirements.
“We also do not believe it is appropriate to restrict recoupment based on a clerical error,” she said. “If a provider bills in error, we should be able to recoup costs paid in error.”
Fawn Barrie, lobbyist for Moda Health, told lawmakers that limiting audits on claims older than 12 months would be a problem, “because sometimes it takes quite a while to actually determine that fact pattern and recognize that there is fraud, waste and abuse.”
