This can’t be ethical?

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bookwormpsych

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Hi. I’m unsure of how to approach this.

There is an individual in my town that does primarily psychological assessment. They see an ungodly amount of people. I’m talking 25 “intakes” (the diagnostic interview, and does not review informed consent to my knowledge) scheduled for 15 minute increments in one day. Then the assessment gets done by some intern, which is scored by someone else, then “dictated” for a report, and written by someone else. Then the feedback is a 15 minute phone call.

Now I know this is not a good practice by any means… but does this cross into unethical practices? It’s like a testing mill. Does this violate some sort of billable hours threshold for insurances? I don’t take insurance so I am unfamiliar.

Is this normal? I’ve never heard of or seen anything like it.
 
Hi. I’m unsure of how to approach this.

There is an individual in my town that does primarily psychological assessment. They see an ungodly amount of people. I’m talking 25 “intakes” (the diagnostic interview, and does not review informed consent to my knowledge) scheduled for 15 minute increments in one day. Then the assessment gets done by some intern, which is scored by someone else, then “dictated” for a report, and written by someone else. Then the feedback is a 15 minute phone call.

Now I know this is not a good practice by any means… but does this cross into unethical practices? It’s like a testing mill. Does this violate some sort of billable hours threshold for insurances? I don’t take insurance so I am unfamiliar.

Is this normal? I’ve never heard of or seen anything like it.
I dunno. I work for the VA and I routinely see veterans referred for 'r/o PTSD' who have been seen by, no joke, like 12 different MH professionals over the past 10 years for a total of like 80 encounters (on inpatient, residential units, outpatient, psychologists, psychiatrists, social workers, you name it) and not one of them has bothered to even do a trauma history consisting of a single sentence. I once saw a case that had 'r/o bipolar disorder' on the notes of a similar number of providers (carried forward, from provider to provider, of course) over the course of about 7 years while that person had encounters with MH professionals of all stripes, again, including on inpatient/residential and outpatient and not one of them did anything to 'r/o bipolar disorder.' I took 5-10 minutes during the C&P exam I was doing to screen for a history of manic or hypomanic episodes. The person failed to endorse any so I 'ruled out bipolar disorder.' The levels of incompetence/laziness in mental health has no capacity to astonish me anymore. I'm not sure what anyone who matters (supervisors, licensing boards) would consider 'incompetence' would even be specifiable by me at this point. Most 'assessments' I have seen do very little to 'move the needle forward' on clarifying differential diagnostic status, enhancing the resolution of the clinical case formulation or producing meaningful recommendations. They usually are chock full with common sense recommendations like 'Mr. X should take his meds as prescribed, attend his therapy sessions, see other providers for continued diagnostic clarification for Y, get a good night's sleep, eat healthy, exercise, and follow the instructions of his medical providers.' Wow. Thanks. For MH providers, as long as you don't sleep with your patients, have a substance use problem, upset the wrong person in power, or fail to respond to Musk's email...I doubt you'll face any consequences whatsoever for 'incompetence' or unethical practice. That's what I've observed over a pretty long career at this point.
 
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Hi. I’m unsure of how to approach this.

There is an individual in my town that does primarily psychological assessment. They see an ungodly amount of people. I’m talking 25 “intakes” (the diagnostic interview, and does not review informed consent to my knowledge) scheduled for 15 minute increments in one day. Then the assessment gets done by some intern, which is scored by someone else, then “dictated” for a report, and written by someone else. Then the feedback is a 15 minute phone call.

Now I know this is not a good practice by any means… but does this cross into unethical practices? It’s like a testing mill. Does this violate some sort of billable hours threshold for insurances? I don’t take insurance so I am unfamiliar.

Is this normal? I’ve never heard of or seen anything like it.
Why are you so concerned with how another person practices, and how is it any concern of yours? If you really feel the need to do something about this (which I do NOT suggest), go speak to the person you are writing about - do it privately and politely.

I strongly suggest you attend to your own practice, whatever it is, and stay out of this. Attempting to intervene will only cause you trouble.
 
Why are you so concerned with how another person practices, and how is it any concern of yours? If you really feel the need to do something about this (which I do NOT suggest), go speak to the person you are writing about - do it privately and politely.

I strongly suggest you attend to your own practice, whatever it is, and stay out of this. Attempting to intervene will only cause you trouble.
Ah yes, the ethical standard of “ignore problems”. I’d forgotten about that.

Does this logic extend to outright abuse or is it just limited to insurance fraud?
 
Hi. I’m unsure of how to approach this.

There is an individual in my town that does primarily psychological assessment. They see an ungodly amount of people. I’m talking 25 “intakes” (the diagnostic interview, and does not review informed consent to my knowledge) scheduled for 15 minute increments in one day. Then the assessment gets done by some intern, which is scored by someone else, then “dictated” for a report, and written by someone else. Then the feedback is a 15 minute phone call.

Now I know this is not a good practice by any means… but does this cross into unethical practices? It’s like a testing mill. Does this violate some sort of billable hours threshold for insurances? I don’t take insurance so I am unfamiliar.

Is this normal? I’ve never heard of or seen anything like it.

Report it if you don't work for them. I work for a managed care corporate team that looks into these things (amongst other things). The provider/doctor can be de-paneled if there is gross deviation from best-practice care (per contract) and/or significant quality of care concerns that would affect a member's livelihood. They can be criminally investigated if there is fraudulent billing, as determined by collaboration between our internal CIU and our internal Medical Directors/Psychologists.
 
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Why are you so concerned with how another person practices, and how is it any concern of yours? If you really feel the need to do something about this (which I do NOT suggest), go speak to the person you are writing about - do it privately and politely.

I strongly suggest you attend to your own practice, whatever it is, and stay out of this. Attempting to intervene will only cause you trouble.
"Cause you trouble?" Are you John Gotti or something? What is this **** advice???

No. Just no.

Don't EVER tell someone NOT to report a potential felony when there is reasonable suspicion and supporting evidence. Terrible. Just terrible. Embarrassing.

Our ethics code say something about this, I think? Can you cite the code? Tell me. I forgot.
 
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No. Just no.

Don't EVER tell someone NOT to report a potential felony when there is reasonable suspicion and supporting evidence. Terrible. Just terrible. Embarrassing.

Our ethics code say something about this, I think? Can you cite the code? Tell me. I forgot.
I can tell somebody *any damn thing I like*. Quote me the provision making you the speech cop, jerk! Oh wait, you are apparently not a mental health professional at all - you are just some managed care guy trying to stick it to providers and patients. What are you even doing on this board ? Can't you find some damaged care forums ?
 
I can tell somebody *any damn thing I like*. Quote me the provision making you the speech cop, jerk! Oh wait, you are apparently not a mental health professional at all - you are just some managed care guy trying to stick it to providers and patients. What are you even doing on this board ? Can't you find some damaged care forums ?
You absolutely CAN NOT tell someone "any damn thing I like" without consequences.
 
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Is it normal? No. However, I imagine that it will be difficult to prove that is going on. Is this insurance based assessment? Cash? Or something like VA disability contract?
That’s what my worry was, ability to prove. It’s a mix of insurance based and cash pay. Maybe some contracts to do custody evals. Mostly private stuff, though. Now, my biggest concern is quality of care. But I also wonder about this - the individual is not currently credentialed/paneled with their own insurance contracts. They are are licensed psychologist, billing under another licensed psychologist’s insurance contracts and license. BUT they are billing as if they are at that person’s practice, which they are not. They practice out of a completely different location. Is.. that normal? I’m not an insurance whiz but I imagine that’s no good either.
 
Why are you so concerned with how another person practices, and how is it any concern of yours? If you really feel the need to do something about this (which I do NOT suggest), go speak to the person you are writing about - do it privately and politely.

I strongly suggest you attend to your own practice, whatever it is, and stay out of this. Attempting to intervene will only cause you trouble.
I am concerned for the clients in this area, quality of care, insurance fraud… ya know, things I think would be normal to be concerned about. But what do I know, I guess ignoring things is your typical standard.
 
That’s what my worry was, ability to prove. It’s a mix of insurance based and cash pay. Maybe some contracts to do custody evals. Mostly private stuff, though. Now, my biggest concern is quality of care. But I also wonder about this - the individual is not currently credentialed/paneled with their own insurance contracts. They are are licensed psychologist, billing under another licensed psychologist’s insurance contracts and license. BUT they are billing as if they are at that person’s practice, which they are not. They practice out of a completely different location. Is.. that normal? I’m not an insurance whiz but I imagine that’s no good either.

Again, hard to know anything without knowing actual evidence, but, a practice with multiple locations is common. Licensed psychologists bill under a practice NPI II while referencing their own NPI I as the rendering provider. What do you mean by saying a licensed provider is billing under another provider's license?

Do you have actual evidence of these billing practices, or are these assumptions? Not saying what they are doing is competent, but clinical incompetence is a lot different than felony fraud, and I would not allege the latter without fairly clear proof.
 
Again, hard to know anything without knowing actual evidence, but, a practice with multiple locations is common. Licensed psychologists bill under a practice NPI II while referencing their own NPI I as the rendering provider. What do you mean by saying a licensed provider is billing under another provider's license?

Do you have actual evidence of these billing practices, or are these assumptions? Not saying what they are doing is competent, but clinical incompetence is a lot different than felony fraud, and I would not allege the latter without fairly clear proof.
Yeah- insurance billing can be overly complex at times. We have some funders where we bill under the agency NPI at the corporate address, some under my own NPI at my satellite clinic address, and some with permutations thereof. What is definitely NOT ok would be billing a service performed by a non-licensed or non-credentialled (by the insurance company) provider as if it were provided by a licensed/credentialled (or more "highly" licensed individual.

For example, if I'm both me and my colleague are licensed psychologists credentialled and eligible to bill Purple Diamond insurance for psych assessment, She can do the intake and feedback, I (or an appropriately trained/credentialled psychometrician) can do the testing, either of us could write the report, and she could do the feedback, as long as all services were performed and appropriately billed as being completed by the person who did them. Depending on the insurance company, there may need to be a primary provider listed on any insurance mandated documentation or forms. I would be certain that all notes and records contain info the specifically identifies the person who performed the service. That's not how we do it, but that might be more common in larger group practices or AMC type setting with multiple clinicians/psychometrists/intern on site- I don't know.

On the other hand- for example- say I'm credentialled with Purple Diamond but my colleague (also a licensed psychologist) is not. Purple Diamond has us bill all services under agency NPI number at corporate address. It would not be ethical/legal for her to do all of the work, have me just sign off on the report and/or be listed as primary clinician, and bill for all the services she performed as if I did them. If I did, say, the intake, scored a test, and gave feedback, we could be for my time spent doing that, by not for her time spent doing the other stuff (at least not billed under psychologist billing codes that require credentialling).

In a private pay setting, it would be different. Basically, as long as you are up front about the services you provide and who will be providing them, and they are actually performed by someone appropriately trained and licensed (if necessary) to do them, probably no-harm no-foul. Such services are often performed under a flat rate (e.g., "$4000 for a full eval, which includes interview, records review, test admin and scoring, and feedback"). In the case of insurance reimbursed services, each specific service (e.g., intake interview; test admin and scoring; feedback) is billed under a different billing CPT code (CPT= Current Procedural Terminology) which pays a specific rate for every "unit" of service. Units are typically 30 or 60 minutes depending on the code being billed, with stipulations about the total proportion of time that need to used to count as a full unit (e.g., a 53 minutes diagnostic interview could be billed as one 60 minute unit of CPT code 90791). OP- sorry if you know all this, but this board is meant for students who my not have this information.

In the case of the clinician referenced in the OP- If they are billing standard insurance codes for diagnostic interviews/intakes (e.g., 90791) I'm curious as to how they could bill 25 of these in one day. I might be wrong, but I think that one unit of 90791 is 60 minutes and that you can't bill in fractions of units. While it might not be unreasonable that some intakes take less than 15 minutes (my clients, for example, only have 18 months of history to review, and 6-9 of those months didn't have much going on). Still- it usually takes a bit longer than that to get information, get initial impressions, discuss targets of treatment and possible differential diagnosis, etc. I'd be suspicious of someone scheduling 15 minute intakes as de facto practice.

In regards to you actually having proof of wrongdoing to take action, I think that is too high of a standard. It's the board (or regulatory/legal authorities in the case of fraud) to investigate and establish proof. I'd say if you have reasonable suspicion based on some form of direct knowledge of what's going on (e.g., beyond hearsay), you have what you need to file a complaint with the licensing board. AFAIK, your name and info would not be provided to the other clinician, at least before any more serious proceedings against them (e.g., if you were deposed or called as a witness). If your suspicions are based on hearsay from someone who claims to have seen wrongdoing, you should at least ask how they got their info and- if they are subject to ethical or legal reporting standards- if they have or plan to file a complaint. If it was another psychologist, I'd let them know that they are ethically obligated to address unethical/illegal practices of other providers.
 
Yeah- insurance billing can be overly complex at times. We have some funders where we bill under the agency NPI at the corporate address, some under my own NPI at my satellite clinic address, and some with permutations thereof. What is definitely NOT ok would be billing a service performed by a non-licensed or non-credentialled (by the insurance company) provider as if it were provided by a licensed/credentialled (or more "highly" licensed individual.

For example, if I'm both me and my colleague are licensed psychologists credentialled and eligible to bill Purple Diamond insurance for psych assessment, She can do the intake and feedback, I (or an appropriately trained/credentialled psychometrician) can do the testing, either of us could write the report, and she could do the feedback, as long as all services were performed and appropriately billed as being completed by the person who did them. Depending on the insurance company, there may need to be a primary provider listed on any insurance mandated documentation or forms. I would be certain that all notes and records contain info the specifically identifies the person who performed the service. That's not how we do it, but that might be more common in larger group practices or AMC type setting with multiple clinicians/psychometrists/intern on site- I don't know.

On the other hand- for example- say I'm credentialled with Purple Diamond but my colleague (also a licensed psychologist) is not. Purple Diamond has us bill all services under agency NPI number at corporate address. It would not be ethical/legal for her to do all of the work, have me just sign off on the report and/or be listed as primary clinician, and bill for all the services she performed as if I did them. If I did, say, the intake, scored a test, and gave feedback, we could be for my time spent doing that, by not for her time spent doing the other stuff (at least not billed under psychologist billing codes that require credentialling).

In a private pay setting, it would be different. Basically, as long as you are up front about the services you provide and who will be providing them, and they are actually performed by someone appropriately trained and licensed (if necessary) to do them, probably no-harm no-foul. Such services are often performed under a flat rate (e.g., "$4000 for a full eval, which includes interview, records review, test admin and scoring, and feedback"). In the case of insurance reimbursed services, each specific service (e.g., intake interview; test admin and scoring; feedback) is billed under a different billing CPT code (CPT= Current Procedural Terminology) which pays a specific rate for every "unit" of service. Units are typically 30 or 60 minutes depending on the code being billed, with stipulations about the total proportion of time that need to used to count as a full unit (e.g., a 53 minutes diagnostic interview could be billed as one 60 minute unit of CPT code 90791). OP- sorry if you know all this, but this board is meant for students who my not have this information.

In the case of the clinician referenced in the OP- If they are billing standard insurance codes for diagnostic interviews/intakes (e.g., 90791) I'm curious as to how they could bill 25 of these in one day. I might be wrong, but I think that one unit of 90791 is 60 minutes and that you can't bill in fractions of units. While it might not be unreasonable that some intakes take less than 15 minutes (my clients, for example, only have 18 months of history to review, and 6-9 of those months didn't have much going on). Still- it usually takes a bit longer than that to get information, get initial impressions, discuss targets of treatment and possible differential diagnosis, etc. I'd be suspicious of someone scheduling 15 minute intakes as de facto practice.

In regards to you actually having proof of wrongdoing to take action, I think that is too high of a standard. It's the board (or regulatory/legal authorities in the case of fraud) to investigate and establish proof. I'd say if you have reasonable suspicion based on some form of direct knowledge of what's going on (e.g., beyond hearsay), you have what you need to file a complaint with the licensing board. AFAIK, your name and info would not be provided to the other clinician, at least before any more serious proceedings against them (e.g., if you were deposed or called as a witness). If your suspicions are based on hearsay from someone who claims to have seen wrongdoing, you should at least ask how they got their info and- if they are subject to ethical or legal reporting standards- if they have or plan to file a complaint. If it was another psychologist, I'd let them know that they are ethically obligated to address unethical/illegal practices of other providers.

This is the rub, considering making improper complaints is, in itself, an ethical violation.
 
Again, hard to know anything without knowing actual evidence, but, a practice with multiple locations is common. Licensed psychologists bill under a practice NPI II while referencing their own NPI I as the rendering provider. What do you mean by saying a licensed provider is billing under another provider's license?

Do you have actual evidence of these billing practices, or are these assumptions? Not saying what they are doing is competent, but clinical incompetence is a lot different than felony fraud, and I would not allege the latter without fairly clear proof.
Yeah- insurance billing can be overly complex at times. We have some funders where we bill under the agency NPI at the corporate address, some under my own NPI at my satellite clinic address, and some with permutations thereof. What is definitely NOT ok would be billing a service performed by a non-licensed or non-credentialled (by the insurance company) provider as if it were provided by a licensed/credentialled (or more "highly" licensed individual.

For example, if I'm both me and my colleague are licensed psychologists credentialled and eligible to bill Purple Diamond insurance for psych assessment, She can do the intake and feedback, I (or an appropriately trained/credentialled psychometrician) can do the testing, either of us could write the report, and she could do the feedback, as long as all services were performed and appropriately billed as being completed by the person who did them. Depending on the insurance company, there may need to be a primary provider listed on any insurance mandated documentation or forms. I would be certain that all notes and records contain info the specifically identifies the person who performed the service. That's not how we do it, but that might be more common in larger group practices or AMC type setting with multiple clinicians/psychometrists/intern on site- I don't know.

On the other hand- for example- say I'm credentialled with Purple Diamond but my colleague (also a licensed psychologist) is not. Purple Diamond has us bill all services under agency NPI number at corporate address. It would not be ethical/legal for her to do all of the work, have me just sign off on the report and/or be listed as primary clinician, and bill for all the services she performed as if I did them. If I did, say, the intake, scored a test, and gave feedback, we could be for my time spent doing that, by not for her time spent doing the other stuff (at least not billed under psychologist billing codes that require credentialling).

In a private pay setting, it would be different. Basically, as long as you are up front about the services you provide and who will be providing them, and they are actually performed by someone appropriately trained and licensed (if necessary) to do them, probably no-harm no-foul. Such services are often performed under a flat rate (e.g., "$4000 for a full eval, which includes interview, records review, test admin and scoring, and feedback"). In the case of insurance reimbursed services, each specific service (e.g., intake interview; test admin and scoring; feedback) is billed under a different billing CPT code (CPT= Current Procedural Terminology) which pays a specific rate for every "unit" of service. Units are typically 30 or 60 minutes depending on the code being billed, with stipulations about the total proportion of time that need to used to count as a full unit (e.g., a 53 minutes diagnostic interview could be billed as one 60 minute unit of CPT code 90791). OP- sorry if you know all this, but this board is meant for students who my not have this information.

In the case of the clinician referenced in the OP- If they are billing standard insurance codes for diagnostic interviews/intakes (e.g., 90791) I'm curious as to how they could bill 25 of these in one day. I might be wrong, but I think that one unit of 90791 is 60 minutes and that you can't bill in fractions of units. While it might not be unreasonable that some intakes take less than 15 minutes (my clients, for example, only have 18 months of history to review, and 6-9 of those months didn't have much going on). Still- it usually takes a bit longer than that to get information, get initial impressions, discuss targets of treatment and possible differential diagnosis, etc. I'd be suspicious of someone scheduling 15 minute intakes as de facto practice.

In regards to you actually having proof of wrongdoing to take action, I think that is too high of a standard. It's the board (or regulatory/legal authorities in the case of fraud) to investigate and establish proof. I'd say if you have reasonable suspicion based on some form of direct knowledge of what's going on (e.g., beyond hearsay), you have what you need to file a complaint with the licensing board. AFAIK, your name and info would not be provided to the other clinician, at least before any more serious proceedings against them (e.g., if you were deposed or called as a witness). If your suspicions are based on hearsay from someone who claims to have seen wrongdoing, you should at least ask how they got their info and- if they are subject to ethical or legal reporting standards- if they have or plan to file a complaint. If it was another psychologist, I'd let them know that they are ethically obligated to address unethical/illegal practices of other providers.
I appreciate you all. I came to this board specifically because you are all straight-shooters and very knowledgeable and I appreciate that.

I will try and clarify, as both individuals I’ve mentioned are people I previously worked for before becoming independently licensed myself. So the knowledge is mostly first hand, things I witness and saw myself. While I understand the use of psychometrists (which was my role when employed by these folks), I never understood the other aspects and whether it was the norm. In terms of the billing, the primary individual I’ve been speaking about is NOT credentialed with any insurance panels at the moment and is using the other clinicians contracts/panels whatever you call them. They bill under an NPI1 rather than the group NPI. So to billing, they’re saying clinician B is providing the services at their practice location, while it’s actually clinician A who is doing the work (well, their interns, anyway) at their separate practice location. Both practices are separate entities and one isn’t the “main” while the other is a satellite office or anything like that. So clinician A is “borrowing” clinician B’s insurance contracts, billing as if clinician B is doing the work, getting paid under clinician Bs license and NPI, BUT clinician A is the one doing the 15 minute 90791s with the multitudes of interns doing the other stuff. Clinician A is at their respective practice doing all of this, while clinician B is at entirely different, unrelated practice.

I guess my goal isn’t necessarily to report, UNLESS there is something that absolutely needs to be reported and that’s what I guess I’m trying to get answers on. While I whole heartedly believe what is going on is wrong and incompetence at its finest in terms of the practices, I was unsure whether this is a violation in terms of ethics or even insurance fraud.
 
That’s what my worry was, ability to prove. It’s a mix of insurance based and cash pay. Maybe some contracts to do custody evals. Mostly private stuff, though. Now, my biggest concern is quality of care. But I also wonder about this - the individual is not currently credentialed/paneled with their own insurance contracts. They are are licensed psychologist, billing under another licensed psychologist’s insurance contracts and license. BUT they are billing as if they are at that person’s practice, which they are not. They practice out of a completely different location. Is.. that normal? I’m not an insurance whiz but I imagine that’s no good either.
Look up the description of the CPT code for the relevant evaluation code. Pay special attention to the ones that say "psychologist", and not "technician".

If you see a legitimate discrepancy between the TIME described in the CPT code and the practices employed by the psychologist: Call up your state's Department of Insurance, and tell them about your concerns. That is an easy thing for them to look into. If you're wrong, no harm no foul. If they are fraudulently billing, they will have to change their practices. You don't have to address the standard of care at all.
 
I appreciate you all. I came to this board specifically because you are all straight-shooters and very knowledgeable and I appreciate that.

I will try and clarify, as both individuals I’ve mentioned are people I previously worked for before becoming independently licensed myself. So the knowledge is mostly first hand, things I witness and saw myself. While I understand the use of psychometrists (which was my role when employed by these folks), I never understood the other aspects and whether it was the norm. In terms of the billing, the primary individual I’ve been speaking about is NOT credentialed with any insurance panels at the moment and is using the other clinicians contracts/panels whatever you call them. They bill under an NPI1 rather than the group NPI. So to billing, they’re saying clinician B is providing the services at their practice location, while it’s actually clinician A who is doing the work (well, their interns, anyway) at their separate practice location. Both practices are separate entities and one isn’t the “main” while the other is a satellite office or anything like that. So clinician A is “borrowing” clinician B’s insurance contracts, billing as if clinician B is doing the work, getting paid under clinician Bs license and NPI, BUT clinician A is the one doing the 15 minute 90791s with the multitudes of interns doing the other stuff. Clinician A is at their respective practice doing all of this, while clinician B is at entirely different, unrelated practice.

I guess my goal isn’t necessarily to report, UNLESS there is something that absolutely needs to be reported and that’s what I guess I’m trying to get answers on. While I whole heartedly believe what is going on is wrong and incompetence at its finest in terms of the practices, I was unsure whether this is a violation in terms of ethics or even insurance fraud.
If you have direct knowledge of illegal (and therefore unethical) activities committed by another psychologist in their role as a psychologist, then you have an ethical obligation (1.04 or 1.05) to do something. Hard stop.
 
If you have direct knowledge of illegal (and therefore unethical) activities committed by another psychologist in their role as a psychologist, then you have an ethical obligation (1.04 or 1.05) to do something. Hard stop.
Absolutely. I was unsure if it was illegal honestly. Thank you for your feedback.
 
It sucks to to be in the position of the OP, and I speak from personal experience having been there myself. It is important, however, that we police ourselves. From a bigger picture, moral/ethical standpoint, we- as a field- recognize the potential vulnerabilities of current and future user of our collective services, and as such seek to protect them from any type of abuse, including financial abuse. Smaller picture- somebody will pay for insurance fraud, including us. We pay personally with higher premiums. Professionally, people who do things unethically can have an unfair advantage by promising potential clients quicker and easier onboarding and service delivery, while those of us who do it correctly and are honest about our services may be presenting longer waits and more time consuming services.
 
f they are billing standard insurance codes for diagnostic interviews/intakes (e.g., 90791) I'm curious as to how they could bill 25 of these in one day. I might be wrong, but I think that one unit of 90791 is 60 minutes and that you can't bill in fractions of units.

I believe the floor, in terms of time. for 90791 is 16 minutes and the ceiling is 90 minutes. Whether or not you can actually do a decent evaluation is another matter. As @Sanman likes to say, insurance doesn't really care about quality of the service being performed and some of us have fewer scruples than others.
 
I believe the floor, in terms of time. for 90791 is 16 minutes and the ceiling is 90 minutes. Whether or not you can actually do a decent evaluation is another matter. As @Sanman likes to say, insurance doesn't really care about quality of the service being performed and some of us have fewer scruples than others.
I'd guess that if an insurance company saw that you were billing 25 units of 90791 or equivalent in a day, they might have some questions.
 
I would hope so. I imagine that the low floor on 90791 was intended for more acute settings.
I couldn't even do that with my current billing system, as 90791 is entered as a 1 hour appointment, so not enough hours in a day to enter 25 of those! It would be harder to identify a pattern of nonsense if it's being build to multiple funding sources. It's the code that I could see most abused, however, as it has relatively high rates compared to the other neuropsych codes.
 
I couldn't even do that with my current billing system, as 90791 is entered as a 1 hour appointment, so not enough hours in a day to enter 25 of those! It would be harder to identify a pattern of nonsense if it's being build to multiple funding sources. It's the code that I could see most abused, however, as it has relatively high rates compared to the other neuropsych codes.

Right, insurance may not catch it if there's multiple payment sources, but it fails the community standard sniff test, even in a purportedly assessment focused outpatient setting. Idk how dafuq how someone thinks they can take a full history in 15-16 minutes. Likely they are moving the goal posts of the evaluation goals in some kind of illogical way.
 
Right, insurance may not catch it if there's multiple payment sources, but it fails the community standard sniff test, even in a purportedly assessment focused outpatient setting. Idk how dafuq how someone thinks they can take a full history in 15-16 minutes. Likely they are moving the goal posts of the evaluation goals in some kind of illogical way.
Yeah- Mondays are my intake day, and I do 4 or 5 maximum. I do them remotely and with clients who literally only have 12-24 months of relevant history to even talk about related to a very specific differential dx. Even talking very quickly I would have difficulty getting through it all in 15 minutes!
 
I believe the floor, in terms of time. for 90791 is 16 minutes and the ceiling is 90 minutes. Whether or not you can actually do a decent evaluation is another matter. As @Sanman likes to say, insurance doesn't really care about quality of the service being performed and some of us have fewer scruples than others.
90791 is technically an untimed code actually. So technically, you can bill for any length of visit.

I do know of folks that do targeted intakes in 30 min (pc-mhi or short-term rehab folks that are not doing a full intake) I have also heard of folks cranking out 20 min intakes for ptsd c&p intakes ( using mostly paperwork with history and self-report scale data)
 
Yeah- Mondays are my intake day, and I do 4 or 5 maximum. I do them remotely and with clients who literally only have 12-24 months of relevant history to even talk about related to a very specific differential dx. Even talking very quickly I would have difficulty getting through it all in 15 minutes!

Even for patients with a fairly straightforward history, 30 mins is kind my bare min for clinical interview. Only way I could see legitimately getting down to 15 mins is if you have a fairly detailed intake form that cuts out a good deal of that.
 
Even for patients with a fairly straightforward history, 30 mins is kind my bare min for clinical interview. Only way I could see legitimately getting down to 15 mins is if you have a fairly detailed intake form that cuts out a good deal of that.
Just finished an intake a few minutes ago. Client turned 1 years old just last week (my youngest ever). Even with such a short history on Earth and him not doing any interaction (or much of anything, for that matter) for a direct observation, parent interview alone took 40 minutes (and I am a big proponent of parsimony in all clinical endeavors). Can't imagine doing a 15 minute intake with anybody older, especially and adult, without missing something crucial that would possibly negatively impact diagnostic or treatment decisions.
 
...Only way I could see legitimately getting down to 15 mins is if you have a fairly detailed intake form that cuts out a good deal of that.
Maybe if you're mass producing WISC or Stanford-Binet assessments for private school applications? If so, there are some things other than short intakes that are concerning from an ethical standpoint!
 
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Even for patients with a fairly straightforward history, 30 mins is kind my bare min for clinical interview. Only way I could see legitimately getting down to 15 mins is if you have a fairly detailed intake form that cuts out a good deal of that.

In primary care, 30-40 minutes was pretty standard but we were upfront with people that these are not comprehensive evaluations and cannot be given the time constraints (i.e.,, "no, this doesn't count as your competency/accommodation evaluation").
 
90791 is technically an untimed code actually. So technically, you can bill for any length of visit.

I do know of folks that do targeted intakes in 30 min (pc-mhi or short-term rehab folks that are not doing a full intake) I have also heard of folks cranking out 20 min intakes for ptsd c&p intakes ( using mostly paperwork with history and self-report scale data)
I've heard mixed things about this. In the setting I do a lot of 90791s in, they're listed as 16 minutes of face to face minimum and 90 minutes as maximum and allow for "care coordination" time aka chart review, talking with other providers, etc. I'm not sure how accurate it is, I have heard some saying it's 30 minutes face to face minimum but I think they're just being arbitrary because they feel like they need more time listed. My stance is if the billable amount does not change from the minimum time to maximum time then doing what is sufficiently needed is what is needed. There's no fraud if someone is spending the minimum time but I would agree extra time is sometimes necessary for clinical sufficiency.

All that said, I think if OP's person of question is doing a lot of these, it's possible they're spending more time reviewing intake forms or supplementary information and wrapping that into the time. 25 a day seems excessive but if they're doing 20 minutes average on each one that's a little over 8 hours a day, maybe 9-10 factoring in documentation time. But i know people who do like 10-12 of these day, depends on setting.


Re-reading OP's post, it sounds like this individual may utilize psychometricians for test administration and either support staff or another provider to type/write the report based off the verbally dictated report. I trained at a group practice years ago that was mostly neuropsychologists and they did the initial interview, passed patient off to psychometrician, and during testing they either saw other clinical interviews, sessions, feedback, and/or writing/dictating other reports. Each neuropsychologist maybe spent 20-50 minutes total with each patient (interview, feedback) spread across two "sessions" and the evaluations were about 6-8 hours of testing done by students, psychometrician, or another psychologist.
 
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I've heard mixed things about this. In the setting I do a lot of 90791s in, they're listed as 16 minutes of face to face minimum and 90 minutes as maximum and allow for "care coordination" time aka chart review, talking with other providers, etc. I'm not sure how accurate it is, I have heard some saying it's 30 minutes face to face minimum but I think they're just being arbitrary because they feel like they need more time listed. My stance is if the billable amount does not change from the minimum time to maximum time then doing what is sufficiently needed is what is needed. There's no fraud if someone is spending the minimum time but I would agree extra time is sometimes necessary for clinical sufficiency.

All that said, I think if OP's person of question is doing a lot of these, it's possible they're spending more time reviewing intake forms or supplementary information and wrapping that into the time. 25 a day seems excessive but if they're doing 20 minutes average on each one that's a little over 8 hours a day, maybe 9-10 factoring in documentation time. But i know people who do like 10-12 of these day, depends on setting.
16-90 min was the previous guidance provided by CMS for billing despite the untimed nature. They used to allow codes 99354 and 99355 for prolonged intakes over 90 min but stopped reimbursing for this in 2023. There is no definitive time limit but there could be clawbacks if the initial is determined to not be appropriately thorough.
 
16-90 min was the previous guidance provided by CMS for billing despite the untimed nature. They used to allow codes 99354 and 99355 for prolonged intakes over 90 min but stopped reimbursing for this in 2023. There is no definitive time limit but there could be clawbacks if the initial is determined to not be appropriately thorough.
I like the way this code is organized- we'll pay you this amount to do what you need to do (if only that amount was more), rather than pay by the hour/half hour. The single fee for a service encourages and reinforces efficiency (admittedly with the trade off of pulling for more dishonesty and crappy/minimal service delivery). As someone who has been doing this awhile and has refined his methods for admin and scoring (e.g., 91636/37), I can do some things relatively quickly without sacrificing comprehensiveness. Result is that I would bill less (and get paid less) for the exact same testing as someone less competent/efficient. Theoretically that would mean I could see more clients, but that just means more reports for me.
 
I like the way this code is organized- we'll pay you this amount to do what you need to do (if only that amount was more), rather than pay by the hour/half hour. The single fee for a service encourages and reinforces efficiency (admittedly with the trade off of pulling for more dishonesty and crappy/minimal service delivery). As someone who has been doing this awhile and has refined his methods for admin and scoring (e.g., 91636/37), I can do some things relatively quickly without sacrificing comprehensiveness. Result is that I would bill less (and get paid less) for the exact same testing as someone less competent/efficient. Theoretically that would mean I could see more clients, but that just means more reports for me.

The timed codes pull for slower service. The untimed ones pull for minimal service and minimal thoroughness with regards to history. Though I agree regarding efficiency.

Until recently, it was also better to code for adjustment d/o and bill psychotherapy rather than bill an hbai code for someone with a Cancer or Parkinsons dx.

RVU requirements also encourage poor therapy practices and discourage high acuity. Much easier to bill for supportive therapy in those with mild sx than an ebp on someone severely depressed.

Overall, the E/M codes for physicians are better but still penalize cognitive work over procedure based work.
 
Intakes are not time based. When I was covering ED, there were times that my diagnostic evaluation was pretty brief due to symptoms. Patient is psychotic and aggressive and ranting about barely intelligible and incoherent delusional beliefs. Unspecified Psychotic Disorder with or without substances depending on the labs, recommend admit and reevaluate tomorrow. That being said, I have rarely done a 15 minute intake in an outpatient setting. I almost said never but I do recall one psychotic and aggressive patient showing up that I spent less than 5. Inures with and the rest of the time getting them safely to where they needed to be. It clearly does not meet standard of care metric, yet that relates more to lawsuits. Incompetent practice or illegal practices are the ethical question and I agree that direct knowledge is part of what I would evaluate. I would be more reluctant to report incompetence as opposed to illegal just because it is more subjective. Ethical standard recommends informal resolution be attempted. I just did that not too long ago with someone marketing themselves as a psychologist who wasn’t licensed in this state and did not understand the regs.
 
I am concerned for the clients in this area, quality of care, insurance fraud… ya know, things I think would be normal to be concerned about. But what do I know, I guess ignoring things is your typical standard.
I don't pretend to be the police, as you apparently do.
 
The ethics class I missed:

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To add to the saga, this individual has all versions of the BASC photocopied and listed on their website as links and part of the intake packets. Which, I do know, violates test security and also Pearson copyright.
 
Forward their site to Pearson's legal team.
My email got sent back. I guess I didn’t send it to the right department or email. Do you have a contact for the US legal team you could message me or general information on how to find the right place to go?
 
"For legal inquiries regarding Pearson Assessments, you can contact Pearson's Clinical Assessment group at 800-627-7271 and ask for the Legal Department, or use the Contact Us form on their website"
Thank you. I tried the contact form but it was all about asking for permissions and what not. I didn’t think to try their general customer support line, I only ever heard the prompts for ordering and what not.
 
Ethics aside, 90791 is not a time duration code so you could hypothetically crank out 25 a day if you were not wanting to be thorough. I also worked inpatient (both psych ER and free standing) and have done my fair share of 10 minute assessments due to AMS so I just type in “unable to assess, patient is actively psychotic” down the entire form and call it a day. So there are situations that could necessitate a short 90791, but outpatient is probably not it.

It is insurance fraud to bill under someone else’s individual NPI. Btw, there’s a whole lot of controversy about whether pre-licensed or associate licensed individuals (postdocs, LMFT associates, etc) can do this (since they will often bill under their supervisor’s individual NPI so patients can use insurance). My former practice decided to only allow those folks to take cash pay to mitigate this, but I know of MANY people who are shadily billing under supervisor individual NPIs. Much more common with the masters level clinicians as we don’t have a structured internship and subsequent postdoc like yall do. I had to report a fellow clinician for doing this. They suspended her license for a few years.
 
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