Series: Medicare Part B Payments for Psychotherapy Services

Announced on 11/15/2017 | Last Modified on 02/19/2025 | Series Number: W-00-24-35801

Status

Completed

Agency

Centers for Medicare and Medicaid Services

OBJECTIVE

Medicare Part B covers psychotherapy services. Psychotherapy is the treatment of mental illness and behavioral disturbances in which a physician or other qualified health care professional establishes professional contact with a patient and, through therapeutic communication and techniques, attempts to alleviate emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development. In calendar year 2016, Part B allowed approximately $1.2 billion for psychotherapy services, including individual and group therapy. A prior OIG review found that Medicare allowed $185 million in inappropriate outpatient mental health services, including psychotherapy services. The review found that psychotherapy services were particularly problematic, noting that almost half of the psychotherapy services reviewed were inappropriate. Specifically, Medicare paid for services that were not covered, inadequately documented, or medically unnecessary. We will review Part B payments for psychotherapy services to determine whether they were allowable in accord with Medicare documentation requirements.

There are 6 projects in this series.

COMPLETED PROJECTS IN THIS SERIES (6)

Audit of Medicare Part B Payments for Psychotherapy Services: Mental Health Center of Florida

Project A-04-21-06251 • Completed on February 19, 2025

Medicare Program Oversight

Project A-09-21-03021 • Completed on May 2, 2023

New York City

Project A-02-21-01006 • Completed on March 29, 2022

On-Site Psychological Services, P.C.: Audit of Medicare Payments for Psychotherapy Services

Project A-02-19-01012 • Completed on July 21, 2020

Grand Desert Psychiatric Services: Audit of Medicare Payments for Psychotherapy Services

Project A-09-19-03018 • Completed on April 20, 2020

Oceanside Medical Group

Project A-09-18-03004 • Completed on August 28, 2019

TIMELINE

November 15, 2017

Series Number W-00-24-35801 Assigned
November 15, 2017

Project Announced
Oceanside Medical Group - A-09-18-03004
May 15, 2019

Projects Announced
On-Site Psychological Services, P.C.: Audit of Medicare Payments for Psychotherapy Services - A-02-19-01012
Grand Desert Psychiatric Services: Audit of Medicare Payments for Psychotherapy Services - A-09-19-03018
August 28, 2019

Project Complete - A-09-18-03004
Oceanside Medical Group has been marked as complete. This audit resulted in 4 recommendations.
April 20, 2020

Project Complete - A-09-19-03018
Grand Desert Psychiatric Services: Audit of Medicare Payments for Psychotherapy Services has been marked as complete. This audit resulted in 6 recommendations.
July 21, 2020

Project Complete - A-02-19-01012
On-Site Psychological Services, P.C.: Audit of Medicare Payments for Psychotherapy Services has been marked as complete. This audit resulted in 4 recommendations.
November 15, 2020

Project Announced
New York City - A-02-21-01006
June 4, 2021

Project Announced
Audit of Medicare Part B Payments for Psychotherapy Services: Mental Health Center of Florida - A-04-21-06251
August 15, 2021

Project Announced
Medicare Program Oversight - A-09-21-03021
March 29, 2022

Project Complete - A-02-21-01006
New York City has been marked as complete. This audit resulted in 4 recommendations.
May 2, 2023

Project Complete - A-09-21-03021
Medicare Program Oversight has been marked as complete. This audit resulted in 6 recommendations.
February 19, 2025

Project Complete - A-04-21-06251
Audit of Medicare Part B Payments for Psychotherapy Services: Mental Health Center of Florida has been marked as complete. This audit resulted in 1 recommendation.
February 19, 2025

Series Complete
Medicare Part B Payments for Psychotherapy Services has been marked as complete.

6 REPORT PUBLISHED

On-Site Psychological Services, P.C.: Audit of Medicare Payments for Psychotherapy Services (A-02-19-01012)

20-A-02-124.01 to CMS - Closed Unimplemented

Closed on 02/01/2024

We recommend that On-Site Psychological Services, P.C. refund to the Medicare program the estimated $3,373,440 overpayment.

20-A-02-124.02 to CMS - Closed Unimplemented

Closed on 08/10/2023

We recommend that On-Site Psychological Services, P.C. based upon the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule25 and identify any of those returned overpayments as having been made in accordance with this recommendation.

20-A-02-124.03 to CMS - Closed Implemented

Closed on 12/09/2020

We recommend that On-Site Psychological Services, P.C. strengthen its management oversight to ensure that it properly maintains treatment plans that contain all required elements, therapeutic maneuvers utilized by clinicians are properly documented in treatment notes, and it properly maintains reliable treatment notes to support services billed.

20-A-02-124.04 to CMS - Closed Implemented

Closed on 12/09/2020

We recommend that On-Site Psychological Services, P.C. implement controls for authenticating signatures on treatment notes.

View in Recommendation Tracker

Psychotherapy Services Billed by a New York City Provider Did Not Comply With Medicare Requirements (A-02-21-01006)

22-A-02-047.01 to CMS - Closed Implemented

Closed on 07/11/2024

We recommend that the New York City provider refund to the Medicare program the estimated $1,118,789 overpayment.

22-A-02-047.02 to CMS - Closed Unimplemented

Closed on 01/16/2025

We recommend that the New York City provider based upon the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

22-A-02-047.03 to CMS - Closed Implemented

Closed on 09/21/2023

We recommend that the New York City provider develop policies and procedures to ensure that treatment plans contain all required elements, are maintained and are signed by the treating physician; the performing therapists and supervising physicians comply with the requirements related to incident-to services; psychotherapy services are conducted by therapists that meet Medicare qualification requirements; time spent on psychotherapy services is documented; and treatment notes are signed and maintained to support the services billed.

22-A-02-047.04 to CMS - Closed Implemented

Closed on 10/28/2022

We recommend that the New York City provider provide training to its therapists on how to properly develop and maintain treatment plans; document that incident-to services were performed under the direct supervision of a physician; document time spent on psychotherapy services; and document and maintain treatment notes to support the services billed.

View in Recommendation Tracker

Mental Health Center of Florida Generally Met Medicare Billing Requirements for Some Psychotherapy Services (A-04-21-06251)

25-A-04-045.01 to CMS - Closed Implemented

Closed on 06/26/2025

We recommend that the Mental Health Center of Florida monitor and evaluate the effectiveness of the QA program updates to ensure that documenting of time spent on psychotherapy services meets Medicare requirements.

View in Recommendation Tracker

Oceanside Medical Group Received Unallowable Medicare Payments for Psychotherapy Services (A-09-18-03004)

19-A-09-141.01 to CMS - Closed Implemented

Closed on 01/19/2024

We recommended that Oceanside Medical Group refund to the Medicare program the portion of the estimated $2,694,446 overpayment for claims that are within the reopening period.

19-A-09-141.02 to CMS - Closed Unimplemented

Closed on 01/19/2024

We recommended that Oceanside Medical Group, for the remaining portion of the estimated $2,694,446 overpayment for claims that are outside of the reopening period, exercise reasonable diligence to identify and return overpayments in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

19-A-09-141.03 to CMS - Closed Unimplemented

Closed on 01/19/2024

We recommended that Oceanside Medical Group exercise reasonable diligence to identify and return any additional similar overpayments outside of our audit period, in accordance with the 60-day rule, and identify any returned overpayments as having been made in accordance with this recommendation.

19-A-09-141.04 to CMS - Closed Implemented

Closed on 05/04/2020

We recommended that Oceanside Medical Group implement policies and procedures and strengthen management oversight to ensure that psychotherapy services billed to Medicare are actually provided, adequately documented, and correctly billed.

View in Recommendation Tracker

Grand Desert Psychiatric Services: Audit of Medicare Payments for Psychotherapy Services (A-09-19-03018)

20-A-09-099.01 to CMS - Closed Implemented

Closed on 02/17/2022

We recommend that Grand Desert Psychiatric Services refund to Noridian $421,272 in estimated overpayments for psychotherapy services.

20-A-09-099.02 to CMS - Closed Unimplemented

Closed on 11/01/2022

We recommended that Grand Desert Psychiatric Services exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

20-A-09-099.03 to CMS - Closed Implemented

Closed on 09/10/2020

We recommended that Grand Desert Psychiatric Services implement policies and procedures to ensure that psychotherapy services billed to Medicare are adequately documented, including the time spent on those services.

20-A-09-099.04 to CMS - Closed Implemented

Closed on 09/10/2020

We recommended that Grand Desert Psychiatric Services strengthen management oversight and review Medicare claims to ensure that psychotherapy services billed to Medicare meet incident-to requirements.

20-A-09-099.05 to CMS - Closed Implemented

Closed on 09/10/2020

We recommended that Grand Desert Psychiatric Services improve its billing system to ensure that Medicare claims identify the correct provider of psychotherapy services.

20-A-09-099.06 to CMS - Closed Implemented

Closed on 09/10/2020

We recommended that Grand Desert Psychiatric Services strengthen management oversight to ensure that psychotherapy services billed to Medicare were actually provided and have supporting documentation.

View in Recommendation Tracker

Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided via Telehealth, During the First Year of the COVID-19 Public Health Emergency (A-09-21-03021)

23-A-09-068.01 to CMS - Closed Implemented

Closed on 08/26/2024

We recommend that the Centers for Medicare & Medicaid Services work with the MACs to recover $35,560 in improper payments made to providers for the 128 sampled enrollee days that did not meet Medicare requirements.

23-A-09-068.02 to CMS - Closed Implemented

Closed on 08/10/2023

We recommend that the Centers for Medicare & Medicaid Services work with the MACs to based upon the results of this audit, notify appropriate providers (i.e., those for whom CMS determines this audit constitutes credible information of potential overpayments) so that the providers can exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any of those returned overpayments as having been made in accordance with this recommendation.

23-A-09-068.03 to CMS - Closed Implemented

Closed on 09/30/2024

Now that CMS has reinstituted most program integrity measures, we also recommend that CMS take the following steps, which if in effect during the audit period could have saved Medicare an estimated $579,667,510 during that period: Conduct medical reviews of psychotherapy services, including services provided via telehealth, to verify that the services are documented and billed in accordance with Medicare requirements.

23-A-09-068.04 to CMS - Closed Implemented

Closed on 02/02/2024

Now that CMS has reinstituted most program integrity measures, we also recommend that CMS take the following steps, which if in effect during the audit period could have saved Medicare an estimated $579,667,510 during that period: Implement system edits for psychotherapy services, including services provided via telehealth, to prevent payments for services that were billed incorrectly.

23-A-09-068.05 to CMS - Closed Implemented

Closed on 09/30/2024

Now that CMS has reinstituted most program integrity measures, we also recommend that CMS take the following steps, which if in effect during the audit period could have saved Medicare an estimated $579,667,510 during that period: Strengthen educational efforts to make providers aware of educational materials on how to meet Medicare requirements and guidance for psychotherapy services, including services provided via telehealth.

23-A-09-068.06 to CMS - Closed Acceptable Alternative

Closed on 09/29/2025

Now that CMS has reinstituted most program integrity measures, we also recommend that CMS work with the MACs to take the following steps, which if in effect during the audit period could have saved Medicare an estimated $579,667,510 during that period: Review MAC jurisdictions' LCD requirements for psychotherapy services to identify which provisions effectively promote program integrity, and consider additional steps that CMS could undertake to ensure appropriate coverage and payment for psychotherapy services across all jurisdictions.

View in Recommendation Tracker

Work Plan Type

Office of Audit Services

HHS Agencies

Centers for Medicare and Medicaid Services

Issue Areas

COVID-19

Target Groups

Elderly

Financial Groups

Medicare B

Series: Medicare Part B Payments for Psychotherapy Services

OBJECTIVE

COMPLETED PROJECTS IN THIS SERIES (6)

Audit of Medicare Part B Payments for Psychotherapy Services: Mental Health Center of Florida

Medicare Program Oversight

New York City

On-Site Psychological Services, P.C.: Audit of Medicare Payments for Psychotherapy Services

Grand Desert Psychiatric Services: Audit of Medicare Payments for Psychotherapy Services

Oceanside Medical Group

TIMELINE

6 REPORT PUBLISHED

On-Site Psychological Services, P.C.: Audit of Medicare Payments for Psychotherapy Services (A-02-19-01012)

Recommendation Details (4)

Psychotherapy Services Billed by a New York City Provider Did Not Comply With Medicare Requirements (A-02-21-01006)

Recommendation Details (4)

Mental Health Center of Florida Generally Met Medicare Billing Requirements for Some Psychotherapy Services (A-04-21-06251)

Recommendation Details (1)

Oceanside Medical Group Received Unallowable Medicare Payments for Psychotherapy Services (A-09-18-03004)

Recommendation Details (4)

Grand Desert Psychiatric Services: Audit of Medicare Payments for Psychotherapy Services (A-09-19-03018)

Recommendation Details (6)

Medicare Improperly Paid Providers for Some Psychotherapy Services, Including Those Provided via Telehealth, During the First Year of the COVID-19 Public Health Emergency (A-09-21-03021)

Recommendation Details (6)