Patient with UnitedHealthcare insurance

[PikminOC]

I am not that familiar with insurance, but my patient has United Healthcare. She sees a therapist that I recommended, and I am concerned about a few things.
The therapist does longer appointments for this complex patient, and emergency after hours calls as well.
She bills the patient for the longer appointments and after hours calls/texts.
One week she billed out 900 for this patient.

With having this insurance and her being a provider within this plan, are these things she is billing for allowed? For example, the longer appointments, the after hour calls, etc? Is this kosher and allowed while being within their rules?

I referred the patient to this therapist and was not aware of these practices she does.
Thanks.

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[splik]

There are two separate issues here. The first is related to what you can bill patients for if you accept their insurance. The second is what is considered ethical and professional practice. You can bill patients for things that insurance won't cover (such as longer appointments and phone calls), and in fact it is good practice to bill for frequent calls. However, if the therapist is encouraging longer sessions for unclear reasons, for their own pecuniary gain, to foster dependence on the therapist, or has poor boundaries that that is very concerning. In most forms of therapy, there is very little that cannot wait until the next session, and if crises calls are frequent, the intensity of therapy should increase. Even in models where 24h access to the therapist is part of it (e.g. DBT), only rare calls are permitted. Marsha Linehan famously hangs up on most patients stating "this is not an emergency."

 

[PikminOC]

That's what I was thinking. I have asked her many times if the patient needs a higher level of care, and she says the patient won't go for a higher level of care. I did not realize until today that the therapist was making this much money off her.

 

[LadyHalcyon]

Specific criteria must be met to use prolonged services codes

That's what I was thinking. I have asked her many times if the patient needs a higher level of care, and she says the patient won't go for a higher level of care. I did not realize until today that the therapist was making this much money off her.

 

[LadyHalcyon]

Just thought it would be helpful to post the guidelines. It sounds like the therapist OP described would have difficulty even meeting the criteria. Is she documenting notes explicitly linking the phone calls to sessions ? Has she proved medical necessity? Although I'm not sure this is explicitly stated, many insurance companies require proof of medical necessity to bill a 90837

what has this got to do with anything? therapists can't use prolonged services codes, and the pile of garbage that is united healthcare isn't going to pay for it. The last time I billed prolonged services for a highly complex neuropsychiatric patient United paid $40 for a 90 minute initial diagnostic evaluation

 

[PikminOC]

what has this got to do with anything? therapists can't use prolonged services codes, and the pile of garbage that is united healthcare isn't going to pay for it. The last time I billed prolonged services for a highly complex neuropsychiatric patient United paid $40 for a 90 minute initial diagnostic evaluation

Correct, but she is in network and has signed up to follow their rules.
If she was out of network this would not be an issue

 

[PikminOC]

This therapist does notes by hand. You know they are crappy notes that dont meet criteria.

 

[TexasPhysician]

It is hard to say how legit it is without seeing how it is billed. If insurance doesn’t cover something or it is outside the terms of the contract, the clinician can bill the patient.

Instead of using a formal IOP with many dysfunctional peers, I have had counselors design something like a personal IOP in an effort to prevent hospitalization. The frequency and duration is often not covered by insurance. On the plus side, patients improve. They prefer the more personalized care, and they are able to continue working.

Is the counselor doing something like this to prevent hospitalization?

 

[PikminOC]

She may be. But if she is in network with united, she has to be correct with billing.
And she was the one who recommended dbt for the pt, but is not following dbt rules.

 

[thoffen]

What difference to you does it truly make if what she is doing is kosher with UHC? It sounds like you (reasonably so) have significant concerns that the therapist has inappropriate boundaries with the patient and is conflicted by her financial reward in failing to sure them up. Perhaps if she's violating UHC rules you have objective validation and that makes it easier. But I think your concern is an ethical one in which you're not sure the patient is getting appropriate care. Take the insurance company out of it. Try and reconcile with the therapist those concerns on behalf of the patient's interest. That's the first step.

 

[WisNeuro]

She may be. But if she is in network with united, she has to be correct with billing.
And she was the one who recommended dbt for the pt, but is not following dbt rules.

Have you had a conversation with the therapist? Ecven simply asking out of curiosity what her approach with DBT is as there are several bastardized versions out there? I don't often rely on solely what the pt tells me when they speak about other providers, because often it can be quite inaccurate according to other objective data that I have.

 

[clausewitz2]

Have you had a conversation with the therapist? Ecven simply asking out of curiosity what her approach with DBT is as there are several bastardized versions out there? I don't often rely on solely what the pt tells me when they speak about other providers, because often it can be quite inaccurate according to other objective data that I have.

It's fun when I get to talk to patients who I, say, discharged from the hospital in an outpatient context and they don't recognize me. "Well, the doctors there told me such and such..." Oh did they now?

 

[WisNeuro]

It's fun when I get to talk to patients who I, say, discharged from the hospital in an outpatient context and they don't recognize me. "Well, the doctors there told me such and such..." Oh did they now?

My usual is when they have a previous eval that I have all of the raw results from and they were clearly malingering, where they deny ever having the evaluation, or make up a story about the provider who did the testing.

 

[PikminOC]

It is just weird because we collaborate on this case and she didn't tell me all of this. Of course, I will talk to her. But she states she is too busy to talk. We set up a time and she goes back and forth for days trying to fit it in her schedule. Now i know why...