APA advice puts psychologists at risk, expert says

APA advice puts psychologists at risk, expert says

National Psychologist Vol. 23, No. 6, p 6. (November /December 2014)


Paula E. Hartman-Stein, Ph.D.

                The APA is advising psychologists to begin efforts to meet compliance requirements under the Affordable Care Act but to await further federal guidance before enacting final plans. An expert in compliance says that advice is off-base and practitioners should prepare full compliance plans immediately.

On Sept. 25, the Government Relations Staff of APA published a Practice Update that stated, “To date, Health and Human Services (HHS) has issued detailed guidance on compliance requirements for nursing facilities, Medicare Advantage plans and Medicare prescription drug plans. HHS has not indicated when it expects to release guidance on the compliance requirements under the Affordable Care Act (ACA) for individual and small group practices.”

James Georgoulakis, JD, MBA, Ph.D., strongly disagrees with APA’s stance of waiting for further guidance from HHS before members develop active compliance programs.

Georgoulakis has written more than 20 articles on Medicare compliance, legally represented psychologists at audits and has served as a consultant to the Center for Medicare and Medicaid (CMS) and the Health Care Finance Administration on mental health payment issues for nearly 30 years.

“The APA is looking for the term mandatory. The Affordable Care Act clearly says a compliance plan is ‘a condition of participation’ in any program that has federal funding,” Georgoulakis told The National Psychologist.

“There are at least 17 videos across the OIG (Office of Inspector General) website that provide guidance on putting together and operating a compliance program,” Georgoulakis said. As far back as 2010 the Health Care Fraud Prevention and Enforcement Action Team (HEAT) published a video, “HEAT Provider Compliance Training: Take the Initiative – Make the Compliance Plan a Priority Now!” It is available on the OIG website.

Georgoulakis cited additional reasons for the urgency to develop compliance plans. They are mandatory for Medicaid providers in a growing number of states such as New York and Texas. Websites have been developed to track providers’ Medicare billing. The OIG has directed CMS to step up their audits in 2015. The investigation of health care fraud and abuse is the one area that President Obama has proposed an increase in the 2015 budget, according to Georgoulakis.

“Under current guidelines, providers who cannot prove that they have taken regular action to eliminate billing errors and to avoid fraud, abuse and possibly waste can be found to have engaged in criminal conduct through deliberate ignorance,” said Georgoulakis.

“This is not the time to wait to develop compliance plans,” he said.

The dangers of noncompliance are clear in a nationwide takedown the Medicare Fraud Strike Force conducted in May. Charges for false billing were issued against 90 individuals in six cities, including mental health services, psychotherapists and psychologists in small practices.

Since its inception in 2007, the anti-fraud strike force has conducted operations in nine areas and has charged nearly 1,900 defendants for falsely billing the Medicare program. The Department of Justice (DOJ) has stated that the only mitigating factor allowed for defendants is a compliance plan.

“Not only do we need compliance plans, we also need compliance programs that include internal monitoring of claims. There are no off-the-shelf solutions. Psychologists should not wait for someone to develop a cookie cutter manual or plan for their office,” Georgoulakis said.

“The Office of Inspector General (OIG) is looking at payment accuracy, improper payments and waste and looks for internal controls in a provider’s practice,” Georgoulakis added.

In his 2014 address to the Health Care Compliance Association, Daniel Levinson, the inspector general of the Department of Health and Human Services, said, “It’s important to appreciate that every compliance plan is different. Things need to be customized.” The OIG website contains his full keynote speech.

Georgoulakis said many psychologists understand fraud and abuse but not the concept of waste in health care utilization. “Waste refers to when a provider is using more resources than other peers are for the same problem,” he said.

In order to demonstrate that a health care provider is not treating a patient excessively, for example, having chart notes reviewed by a knowledgeable peer is part of an active compliance program. Some practices try to cut consulting fees by having only a small number of clinical notes reviewed annually.

“On the OIG website there is a statistical program, RAT-Stats, in which the provider can plug in the number of Medicare sessions conducted in a year and the program tells you how many records to have reviewed. For a small individual practice, a bare minimum of 30 clinical notes should be reviewed. The number is not based on how many Medicare patients a clinician treats but by the number of visits,” Georgoulakis said.

He cautioned that 30 is not a static number and the rules about compliance programs change frequently.

Additional topics on the OIG website include proactive reviews, coding, contracts and quality of care. Georgoulakis said participating in the Physician Quality Reporting System (PQRS) demonstrates a practitioner’s concerns about quality of care.

“Psychologists can choose to be like the ostrich, put their heads in the sand and wait until some magical guidance specifically for psychologists is released or we can be like the eagle and strive to be a leader with his great sight to see where health care is going.”


Paula Hartman-Stein, Ph.D. is a clinical psychologist in private practice, educator and consultant to small group practices. She serves on three technical expert panels for PQRS measures and produces educational webinars and DVDs on psychology practice issues. She can be reached from her website: www.centerforhealthyaging.com.


“How to Develop a Mandatory Compliance Plan for a Psych practice”

Now available is a new 68 minute DVD covering practical information on how to develop a compliance plan that meets the minimum one hour annual training required, one of the 7 elements. A certificate attesting to your training that can be placed in your compliance manual will be sent via email.

Cost of 68 minute compliance training DVD and attestation certificate:
$197 including postage and handling
Please allow 2 weeks for delivery



Produced by the Center for Healthy Aging, Kent, Ohio, 2014