Medicare Billing Mistakes That Could Land You in Legal Trouble

Hey there everybody. Doc Snipes here. Today we're talking about preventing paybacks and fraud for Medicare and Medicaid behavioral health billing. I'm your host, Dr. Donnelly Snipes. Over billing on Medicaid is something that is rampant in the behavioral health care field. Whether it is therapists or case managers, I see it a lot and I like to believe that it's people who are unaware of the rules inadvertently over billing Medicaid. In either event, if you are in a clinic that bills Medicaid, it is essential that you pay attention to whether your staff is rounding up to the next billable unit. Many Medicaid services are billed in 15 minute increments and are only allowed to be rounded up if more than eight minutes of the next unit are spent with the patient. So if spend 15 minutes with the patient, that's one unit. Okay, you bill $6.40. If you spend 20 minutes with the patient, that's 15 minutes plus five. Well, that doesn't meet that eight minute threshold. So you can still only bill one unit. If you spend 23 minutes to 30 minutes with the patient, then you can round up and bill for that full two units. Now when we say with the patient, that's what we mean with the patient. It doesn't mean five minutes with the patient. And 10 minutes doing paperwork means those minutes actually have to be engaged with the patient. And both of those are areas where people get into a lot of trouble. They count their documentation time and they round up when they're not supposed to. Please be aware of this. Please educate your staff and randomly audit to make sure that people are rounding the correct way. Another issue that comes up is over billing on Medicare. Now Medicare and Medicaid are very different programs. Medicare tends to bill in time based increments, but it's not units like we see in Medicaid. Either way, one of the interesting things in behavioral health is there's a higher per minute reimbursement for shorter sessions. So if you're seeing a patient and you're for allegedly 30 to 37 minutes and billing 90832, you may be able to bill up to $4.75aminute. Well, how does that happen? Because even though you're supposed to be spending 30 to 37 minutes with the patient, you only have to spend a minimum of 16 minutes with the patient. So 16 minutes with the patient gets reimburs at $76. Just like 37 minutes with a patient gets reimbursed at $76. Now I think that's a flaw in and of itself in the Medicare structure. But it's also important to recognize the spirit of the regulation. The Medicare regulation that says you have to spend a minimum of 16 minutes isn't trying to encourage you to only see people for 16 minutes and bill for 30. It's trying to encourage you to see the patient for however long they need. Every once in a while you may engage with somebody and after 16 or 20 minutes, they are cognitively just done and they're not able to focus. Whether they've just had surgery or they're postpartum or they're in an assisted living facility, something's going on. Or maybe they're, they're sick. Maybe you're doing a telehealth session and they're sick and they're just like, doc, I can't do anymore. Okay, you can still bill that. So Medicare doesn't want you to be out the money if you don't do the full 30 minutes. But that's supposed to be most of the time the exception, not the rule. Then you have 90834, which is a 45 to 52 minute session, minimum of 38 minutes. And that gets reimbursed at $101. A lot of therapists round up and they include, and you're not supposed to, they include their documentation time. So they only see the patient for 50 minutes. Because a lot. It's typically known that the therapy hour is 50 minutes. So they see the patient for 50 minutes and then spend 10 minutes doing documentation. So they think they are justified in billing 90837, which is $149. So they're getting $48 for 10 minutes of documentation. That's not how it's supposed to work. So I'll give you another example using the 90832. If you're in a large hospital or assisted living facility and there are 100 residents and 120 of them want therapy. Wow. You know, if that happened, I'd be over the moon because I'm like, hey, people want to get healthy. But anyhow, I digress. A therapist can only bill for about 32 hours a week because the rest of that time has got to be spent doing documentation. Okay. Ethically, a provider could theoretically bill $4,864 per week by billing 90832 and seeing 64 of the patients who want to be seen. Why 64? Because that is two patients an hour, one patient every 30 minutes. And that's what, 90832 is supposed to be for. So that is ethical and that works. And some people are fine with a 30 minute session. There's a loophole though. Because of that minimum 16 minutes, providers can actually over bill by up to 46% and actually end up billing $9,120 a week by because they're billing 90832 but only seeing the patient for 16 minutes. So they can see a lot more patients per hour. That's not how Medicare intended it. Medicare, if they intended to have a 16 minute session, they would have had a billing code for a 16 minute session. So the 16 minute minimum is the exception, not the rule. And the rule, because it actually says 90832 is psychotherapy 30 to 37 minutes, the rule is you're supposed to be hitting that 30 to 37 minute mark. So intentionally and consistently billing 90832 for 16 minutes is abuse of the system. I'm not talking about doctors in this particular video because doctors have totally different codes that are much more granular. They have codes that go all the way down to spending five minutes minutes with the patient. We don't have that in behavioral health. So I'm not touching on that today. What I am touching on is your outpatient mental health billing, your clinic mental health billing. And Again, your main CPT codes that that are used in outpatient are 90832, 90834 and 90837. If you're not spending at least 53 minutes with the patient, you cannot bill 90837. 90837 is the most commonly billed CPT code for behavioral health. It's standard practice in individual therapy to see people for an hour. And again, you need to see them for at least 53 minutes. You can't stop it at 50 minutes. But older adults, especially those with cognitive decline or people who have comorbid physical health issues or on heavy medications for some reason may not be able to stay focused for a full hour. We do need to use our clinical judgment. If your person is not going to benefit from 53 minutes of therapy, then you need to back it down and either bill a shorter session well or and bill one of the shorter sessions. As behavioral health professionals are able to go into nursing homes to provide care which just started In January of 2024, the appropriateness of services needs to be examined. 90832 the full 30 minute session, not the 16 minute. 90832 may be more appropriate in, in many cases. And for some patients, seeing them Twice in a week for. For 30 minutes may be way more beneficial than seeing them once a week for an hour. And ultimately the billing works out at right about the same example of how this might get abused. Jane is working in XYZ assisted living facility, and there's 50 residents, but only 15 of them want services. Now remember, we can bill up to 32 hours in a week. She's only got 15 patients, so that she's going to see in this scenario, to pad her billing, Jane may bill as if she saw all 15 patients for a full hour, even if she only saw them for 30 minutes each. And that's a little bit more obvious fraud. But we do start seeing that padding and that rounding up and the creep in, in billing because people want to earn more money. They're like, well, I don't have the patience but to see people every 30 minutes. So let me say I saw this person for longer. Again, that's not okay. And one of my favorites, I guess, documentation errors. Over the 25 years that I worked in behavioral health, nearly 20 of them in community behavioral health. In Medicaid billing facilities, nearly 20% to 25% of patient documentation was inadequate in order to get reimbursed by Medicare or Medicaid. When you are taking Medicaid or Medicare, they have very specific documentation requirements for the intake, for the treatment plan, for the progress notes, for treatment plan revisions and rewrites, for and for reassessments. If you're not getting all of the documentation that you need, if you're not getting all of the information that you're expected to have in the intake, if you're not getting the signature on the treatment plan, then any of the services you provided are potentially able to be cla clawed back. Medicaid can come in and say, nobody ever signed this treatment plan, so you got to pay it all back. None of the services were valid for payment. Same thing is true with the intake. If you go in and do a sloppy intake and you don't get all of the information. And in the provider manual, Medicaid and Medicare both are very specific about the detailed information you need to get. And if it's not in there, you could end up having an auditor say, well, you didn't get all the information needed for the intake, so we're going to disallow all of these services. If you do a great intake and you do a great treatment plan and you even get it signed, you know you're all compliant, and six months passes, you're still seeing the patient and you don't do the treatment plan, update every service you provide to, to the patient from the time the treatment plan expired until you figured it out, all of those are potentially going to be paybacks. It can get really expensive really quickly. It's also important to note because a lot of people are going, well, I've been billing Medicaid for years and I've never had a problem. Well, guess what, they're years behind. They are just now. Medicare and Medicaid are just now auditing in most cases, especially Medicaid, Medicare, 2018 documentation. And we're in 2025. So they're like seven years behind. So what you're billing today, seven years from now, they could come back to you and go, well, if you don't have this documentation, you got to cough up all this money. You owe us these millions of dollars. And trust me, they do. Roughly 15,120,000,000 per year is potentially eligible for clawbacks from Medicaid alone just based on documentation errors. If 20% of the patient documentation is inadequate, 15 billion, that's a big stinking number. Adequate documentation produces quality treatment. I'm with you. I hate doing documentation. I hate writing it. I'd much rather just, you know, talk to the patient, get a feel for the situation. But that's like, like trying to build a house. You go to Home Depot and you get a whole bunch of lumber and nails and whatever else you need and you take it out to the building site and you just think, you know, let me figure out how I'm going to put this together. And you're writing, drawing the blueprint, blueprints on the fly. That is not the way to create a safe, sound building, and that's not the way to create a effective, efficient treatment plan. Intake gives you the foundation information you need. Treatment plans identify your goals and how you're going to achieve those goals. And progress notes help you keep tabs on how effectively you are meeting those goals. They are essential to gather information needed, develop efficient and effective individualized approaches, and monitor effectiveness. Otherwise, and I've seen it a lot, especially in private practice settings, therapy can turn into more of a chat session. And that's not what therapy is. Therapy is designed to help you identify obstacles to your rich and meaningful life and move toward them. So when therapists are not doing adequate intakes, treatment plans, and progress notes, they're failing you. And this is true whether you've got Medicaid, Medicare, or private insurance. Every therapist should be providing, should be completing a thorough intake and Providing you, working with you to develop and providing you a treatment plan. With my patients, at the end of every session we go over, we review what was accomplished in that session and how it helped them move toward their goals. So we essentially write the progress note for before they leave my office. And that's important because it helps patients see what they're doing and how it applies to their progress forward. It's a very empowering thing to do. Another one that is abused quite a bit in all insurance, not just Medicare and Medicaid, is medical necessity. And in behavioral health, just like other fields, it can be abused. A person with depression, an anxiety, addiction or ptsd, who's getting adequate treatment. If you're providing effective quality treatment, you're defining treatment plan goals and you're achieving those goals, that's great. They are unlikely to consistently need 60 minute sessions every week for three plus years. You're walking them through their goals and when they achieve their goals, a lot of times they take a break. Now that doesn't mean they can't come back sporadically and have multiple episodes of care in three years. But it is rare, extremely rare, that someone needs to be seen by a therapist for therapy every week for three plus years. That's just, that's not okay. And it really is somewhat unethical because it establishes a dependency on the therapist. Now, people with recurrent major depression, bipolar or addiction, as I said, often benefit from multiple episodes of care, but it's not continuous. They'll do three months of treatment and they'll reach a really good stopping point where they're, they feel stable, they're on a plateau and they'll ride that out. They'll solidify those skills for a while. Then when they're ready to climb the hill again, they'll reenter treatment. People with severe and persistent mental illness like schizophrenia, well, they do need ongoing care, but it's usually in the form of case management and supportive services. Rarely does somebody with schizophrenia benefit from ongoing weekly psychotherapy for years at a time. Now, there are times where episodes where a therapist can be helpful to help people adjust to their diagnosis, to help people adjust to changes and life circumstances, etc, but again, those are episodic. And too often therapists get very comfortable with a client who shows up every week like they're supposed to. They don't cancel, they always pay their bills. So therapists are reticent to discharge them because they know that that is a consistent source of income. Hate to say it, but that's really what it is. Sometimes therapists and again, this is unethical, but they like working with this patient, they enjoy working with this patient. And even if the patient has reached maximal gains at this level of care, they want to cons continue seeing that patient because it's an enjoyable hour and therapy is not supposed to be there to be enjoyable. With the advent of artificial intelligence, I'm also seeing a lot more remote patient monitoring being billed for people with behavioral health conditions like depression and adhd, in which remote patient monitoring is not necessary. Remote patient monitoring is when a patient wears a device 24, 7 and the device regularly reports in to the doctor's electronic health record. So the doctor is getting sort of real time data, if you will, or close to real time data. And for certain things that may be really helpful if somebody's got a heart problem, for example, really helpful. But for monitoring somebody's activity, how many steps they're taking, or their heart rate variability, or how much they slept most of the time. For mental health conditions you don't need real time reporting. The person can get a fitness tracker and report to the therapist every week when they come in. This is how much I slept. You know, here are my sleep logs, here are my step logs. And then Medicare or Medicaid doesn't have to pay for that. Now there are times where it can be useful in behavioral health, but most of the time remote patient monitoring is most effective in people who have physical conditions like diabetes and having the continuous glucose monitor report in or if they, like I said, they have a heart condition so the doctor can track the arrhythmias. Those are things that we want to see the remote patient monitoring for. They do have little pill bottles now that somehow, and I'm not sure how record when a patient has taken their medication. That can be helpful for people who have difficulty with medication compliance and people with schizophrenia monitoring that. But we do need to use common sense. Is this something that needs to be tracked in real time or is this something that I could get from my patient each week when they come to session? And finally, I think supervisory and incident 2 building billing, some private insurance companies. And when I say private insurance, I mean other than Medicare, Medicare Advantage and Medicaid. So your blue crosses, your blue blue cross and Blue shield, your Aetna's, your Cignas, etc for the younger population. Some private insurance companies allow a licensed supervisor to bill for services provided by their unlicensed supervis. But this is the exception, not the rule and it varies by state. If you're with an insurance company, you're paneled with an insurance company in Tennessee that allows supervisory billing. So you're a licensed practitioner and you can have an intern or a temp licensed therapist as we call them in Tennessee, provide services and you can bill for the services as if you provided them. The thought is that that allows people who are pre licensed to get their hours. However, most insurance companies actually don't allow this. Most people don't realize this. So they are billing insurance companies for supervisory billing. And it's not allowed. You could have an incident, for example, if you are a licensed person and you have three pre licensed people working underneath you and they're seeing patients every single hour. Eventually Blue Cross may get a bill, for example, from your, from you, for patients that your supervisors saw. And it looks like you saw three patients for individual therapy in the same hour because all three of them happen to have Blue Cross and Blue Shield. And that's when the red warning flags go up and you start getting audited. It is imperative to check your contract to see if you're allowed to do incident to or supervisory billing. Medicare and Medicaid. Well, let me rephrase that. Medicare never allows a licensed behavioral health provider to bill for services provided by an unlicensed person. Supervisory billing is not allowed with Medicare. Medicaid rarely allows for it. And most of the time it has to be a special caveat in your contract where Medicaid says okay, under these conditions, an unlicensed person can bill. It's important to know your contracts. Tennessee Medicaid is much more rigid, for example, than Florida Medicaid. Florida Medicaid has a whole list of services that bachelor's level providers can provide and bill for. We don't have that in Tennessee. So know your contract. PTANs are something that we use in Medicare billing. And if you have a ptan, you're credentialed, so to speak, with Medicare you have a ptan and, and you have supervisees under you and you're allowing them to use your PTAN to bill for services. That's illegal. It's just flat illegal. Incident two is another interesting little loophole that's getting abused wildly. When we were granted the ability to bill Medicare incident 2 in 20, or sorry, bill Medicare in 2024, it specifically disallowed incident 2 billing. We cannot bill incident 2. So we can't be the provider as an LPC, LMHC or LCSW. We can't be a provider and allow somebody else to bill, basically using our number, which is sort of a different version of supervisory Billing it's really important to recognize. And if you are providing services, for example for a doctor's office, you also can't bill incident 2. The doctor has a PTAN and you are able to get a ptan. So Medicare says, well, you can't bill incident two under the doctor, then you've got to bill under your own ptan. The short version. In behavioral health, we cannot bill incident two, we cannot be billed for incident two, and we cannot use any form of supervisory billing unless it is specifically stated in your contract. Now that's Medicare. Like I said, Medicaid does have some wiggle room depending on what state you're in, which is why it's so important to have your contract and know your provider manual. Oh, I forgot one more CO insurance. This is another one that gets under my saddle. Many organizations, especially lab companies, and I'm going to call them out because I spent 20 years working in community behavioral health in co occurring facilities and addiction treatment facilities and lab companies are horrible about this. Many organizations, especially lab companies and addiction treatment centers, are known for negotiating reimbursement rates that are 120% of what they need. So if I need a hundred dollars for services to make my bills, if what I want to get back, what I want to earn is a hundred dollars, then I am going to negotiate for $120 because I know that Medicare Part B pays 80% and the person's supposed to pay 20% co insurance. Well, I don't want to bother them with that. I want them to like me and I want them to use me. So I'm not going to bill them for their CO insurance. I'm just going to charge Medicare more for my services. That's a big no, no. That is illegal. That's a big no no. This incentivizes providers and patients to use these companies because you know, who wouldn't want to avoid paying 20% of their medical bill? But it's illegal. And habitually waiving CO insurance can get providers in a lot of trouble. Typically, the expectation is that you bill people for services you build, build them for their copay. If they don't pay you, follow up at least twice in order to try to get the monies. And at any point along the way, if they're willing to, you know, start doing a payment plan, that's fine, but just writing it off, just saying, oh, don't worry about it, that's not okay because ultimately it means the providers are going to charge Medicare a lot more to cover for the co. Insurances that they're not getting. There are many issues that can cause paybacks in Medicare and Medicaid. There are many ways people have found to abuse the Medicare and Medicaid system, both medical providers and behavioral health. I'm speaking to behavioral health because we have recently been granted the privilege of being able to bill Medicare. And I'm really concerned we're going to quickly lose that privilege. And I've seen Medicaid being abused in behavioral health for literally decades. If we improve our documentation and reduce waste, fraud and abuse in Medicare behavioral health billing, we could provide more effective services to those who truly need it. If we're providing therapy with an intake and a treatment plan that are, you know, compliant, then we have a good blueprint for what we're doing that makes for much more efficient and effective therapy. I know this is not a typical video that I do, and I know for some people it was probably a little boring, but I am passionate about compliance and I am passionate about saving companies money in, in the form of paybacks. So if you have any questions about your documentation, if you have any desire to have an audit, have me come in and do an audit and identify areas where you may be at risk of paybacks. I am more than happy to do that and you can reach out to me at support@docsnipes.com for now, thank you and have a good day.