More on those EquiClaim/Blue Cross Letters and 90837 Profiles: An Interview with EquiClaim (by Barbara Griswold, LMFT, March 7, 2016)

Last month’s feature article focused on letters providers received from a company called EquiClaim on behalf of Blue Cross (or one of several other insurance plans). These letters were sent to therapists who use CPT code 90837 (sessions over 52 minutes) “more frequently than their peers” (to read last month’s article click here). Panicked recipients flooded my inbox with questions.
As promised, I investigated further, and had an extended interview with an EquiClaim Coding Advisor.  Here are some of her answers to my questions:

Who received the EquiClaim letter? According to the rep, this letter was sent to thousands of network providers on behalf of Blue Cross, AmeriHealth, and one other health plan, to providers in California, Nevada, Colorado, Central New York, New Hampshire, Connecticut, Virginia, and Georgia, and will soon go to Alabama and Minnesota providers.  Some out-of-network therapists received the letter, but this was a mistake.

So, are the health plans looking to collect money? The rep acknowledges that the letter may have mistakenly given this impression, so they have removed the sentence from future letters that identified the program’s intent as “…identifying any improper coding and recovering associated overpayments.” She stressed financial recoupment is NOT the purpose of the program.

What if I just choose to routinely provide sessions longer than 52 minutes?  That’s just fine, according to the rep.  She stressed repeatedly that this is NOT an attempt to change provider session length, but instead is a campaign to ensure codes are being used accurately and documented appropriately. The rep said she was sorry to hear that some providers are switching to billing for 90834 (38 – 52 minutes) even when providing 90837 sessions to avoid a possible records review. “It was not the intention of the program that providers be paid less than they should be for the services they are providing,” she said.

If I continue to bill regularly for 90837, can I expect a records review?  “It is just a possibility,” she said. “You can expect another letter and above-average profile, probably at the end of May. After that, you might get a records review request.”

What would a records review look like? You would be asked to fax or mail records related to 10 randomly selected sessions, possibly for multiple covered clients. She stated they will not go back and look at dates of service prior to the letter. They are giving providers the opportunity to improve documentation habits, as needed.

So what will they be looking for?  According to the EquiClaim rep, they are not asking providers to defend the medical necessity of the longer session.  They will be looking for the documentation elements required by the plan, including session start and end times.  While you can contact EquiClaim of the health plan and request the plan requirements in your state, see my article on documentation for a helpful guide to what should be in your documentation.