‘Medically unnecessary’ is OIG’s answer to testing.


By Paula Hartman-Stein, Ph.D.


            About 39% of psychological testing services conducted for nursing home patients in 1999 were medically unnecessary, according to a recent report by the Office of Inspector General (OIG).


In dollar figures, OIG estimated $22.6 million of inappropriate payments during 1999 for the total Medicare population.


During inspection of 450 psychiatric services in nursing homes during the first half of 1999, the OIG reviewers found 27% of the services to be medically unnecessary, 9% lacking any documentation, and 3% questionable due to the patients’ low cognitive functioning or incomplete records.


When OIG released results of a similar study in May 1996, it found nearly half of all Medicare psychiatric services in nursing facilities were medically unnecessary or questionable.


             The most problematic services reviewed were in the category of psychological testing, an area in which the Health Care Financing Administration (HCFA) has not yet assigned work values that include codes 96100, 96105, 96110, 96111, 96115, and 96117.


            James Georgoulakis, Ph.D., explained that HCFA views that psychological testing has both a technical and professional component.  Georgoulakis expressed concern that HCFA’s assessment of the amount of professional time will be lowered in psychological testing because of the unfavorable OIG report.


Leslie Fried, associate director of the American Bar Association’s (ABA) Commission on Legal Problems of the Elderly, said she fears the OIG report will have a “chilling effect” on mental health services, especially for cognitively impaired older adults. The current OIG report, she said, sends a strong message to nursing homes to avoid providing behavioral health services or  not to accept patients with mental illness.


While the OIG issued an unfavorable report, the office of the Surgeon General in January presented an opposite view, describing the difficulty nursing facilities have in obtaining services of mental health professionals due to inadequate reimbursement policies.  The Surgeon General’s report, Older Adults and Mental Health: Issues and Opportunities, acknowledges the high prevalence of dementia and depression in nursing facilities and lists barriers to adequate treatment of frail seniors.


As a result of the OIG report, Fried said it is “vital and urgent” for professional associations to meet with carrier advisory committees and carrier medical directors to discuss mental health policies at a local level.  As of Jan. 2001, Medicare contractors were required to post their draft Local Medical Review Policies at www.draftLMRP.net.   This will enable providers and their associations greater awareness of proposed changes in local Medicare policies and provide the opportunity for dialogue and education of their carriers  OIG report:  www.hhs.gov/oig/oci


Hartman-Stein, P.E. (2001) ‘Medically unnecessary’ is OIG’s answer to testing. The National Psychologist, Vol. 10, No. 2, p 3.