When Steven R. Cohen, Ph.D., a practicing psychologist in Philadelphia, received a call in 1999 from Pennsylvania Blue Shield, he was told to prepare to be audited for “overuse.”
The audit would focus on CPT Code 90844, which has since been changed to 9086 denoting 45-50 minute individual therapy sessions.
Endless letters and phone calls ran their course. Eventually, Blue Shield notified Cohen that its representative would be arriving at his office to explain why Cohen owed them $38,000.
$38,000! Cohen thought it was a scam, that corporate scam artists were trying to extort funds from him.
Cohen soon found out that Blue Shield disallowed many of the sessions the company had audited, claiming they were not medically necessary. Then, using a secret calculation, they applied the per cent of disallowed sessions against all of his Blue Shield clients for the past several years. “Voila, we owed $38,000 having done nothing wrong,” says Cohen.
But the Philadelphia psychologist wasn’t about to surrender. A two-year battle began involving letters, documents changing hands, numerous professional hours which he termed “wasted.”
The ultimate outcome, according to Cohen: “Blue Shield continued to demand $38,000. We paid Blue Shield nothing.”
He explained: “We believe these audits are not about uprooting fraud or improving patient care, but about making money.” Cohen said he asked Blue Shield if he saw patients more frequently or for longer periods than other therapists, but they answered that his only sin was his frequent use of procedure code 90844.