OIG audit reveals $2.6 million in overpayments for psychotherapy services

November 11, 2019
Medicare Web

An August report from the Office of Inspector General (OIG) found that Oceanside Medical Group, a clinic providing mental health services in Santa Monica, California, received $2.6 million in overpayments for psychotherapy services by failing to comply with Medicare billing and documentation requirements.

The OIG reviewed Oceanside’s Medicare Part B claims for psychotherapy services provided from July 1, 2015, through June 30, 2017. The agency selected a random sample of 100 beneficiary days, which included 103 individual psychotherapy services:

  • 51 for 30 minutes of psychotherapy with an E/M service; billed using an E/M code and CPT code 90833 (psychotherapy, 30 minutes with patient when performed with an E/M service)
  • 43 for 30 minutes of psychotherapy; billed using CPT code 90832 (psychotherapy, 30 minutes with patient)
  • 9 for 45 minutes of psychotherapy; billed using CPT code 90834 (psychotherapy, 45 minutes with patient)

The OIG’s auditors determined that none of the 100 sampled beneficiary days complied with Medicare’s requirements. Specifically, the auditors determined that:

  • Psychotherapy was not provided for 52 services.

They could not find data in the medical records indicating that these psychotherapy services had been administered.

  • Psychotherapy time was not documented for 49 services.

Providers didn’t bill the psychotherapy CPT codes based on the actual time spent on psychotherapy (e.g., CPT codes 90832 and 90833 may be reported for 16 to 37 minutes of therapy, and CPT code 90834 may be reported for 38 to 52 minutes of therapy).

  • Adequate supporting documentation was not provided for two services.

Oceanside did not provide documentation that was created on the date the services were provided.

The OIG recommended that Oceanside repay a portion of the estimated $2.6 million overpayment for claims that are within the reopening period. For claims outside that period, the OIG recommended that Oceanside identify and return overpayments according to the 60-day overpayment rule. The agency also recommended that Oceanside implement policies and procedures and strengthen oversight to ensure that services are correctly provided, documented, and billed.