Oxford Health seeks repayment for past mental health services

By Mary Lou Bernardo, Ph.D.
November 1, 2003

In an unprecedented move, a Connecticut-based health maintenance organization is seeking hundreds of thousands of dollars in repayment from New York area mental health professionals, claiming their notes did not support charges made during the past five years.

Oxford Health Plans looked at notes and records of 300 therapists during the last two years and concluded that their notes were inadequate to document many of the sessions the company had paid for since 1998.

In other cases, Oxford asserted that the notes indicated a shorter session had taken place and requested repayment accordingly (see sidebar).

Therapists that were audited included 100 psychologists, 100 psychiatrists and 100 clinical social workers.

Though practitioners in the New York metropolitan area were hardest hit, therapists from other states were quick to rally in support of those being audited. While no one is disputing Oxford’s right to prevent fraudulent payments, the method used to audit the notes seemed designed more to save money than root out unscrupulous therapists, many say.

Robert Erard, Ph.D., clinical and forensic psychologist in private practice and former chair of the Insurance Committee of the Michigan Psychological Association, said, “It seems to me that these audits are kind of a poor man’s utilization review. In this case, the company is coming in the backdoor and deciding, using secret criteria, whether the treatment was medically necessary after all.

“This is an obvious conflict of interest where they find deficiencies after the fact. They have an incentive to find deficiencies.”

One Connecticut psychologists in private practice, who requested anonymity, termed Oxford’s move “sleazy. This has nothing to do with clinical practice. It’s about money. A class action against Oxford seems justified.”

Donald Bernstein, director of professional affairs for the New Jersey Psychological Association, called the move “puzzling.”

“It makes you wonder if it’s really an attempt to get something else,” Bernstein said. “It’s a broadside attack against providers of all stripes.”

Steve Karp, executive director of the Connecticut Chapter of the National Association of Social Workers, wonders, “Assuming they were doing an ongoing review via OTR’s, why are they now denying payment?”

Gayle Everitt, J.D., executive director of the New York State Psychological Association, said that an unknown number of practitioners have returned money to Oxford. She advises any psychologist that receives a letter from Oxford to contact an attorney.

Daniel Abrahamson, Ph.D., who represents the Connecticut Psychological Association on the American Psychological Association Council of Representatives, said he feels fortunate that Oxford didn’t contact therapists in his state.

In addition to the matter of repayment of fees, psychologists and other mental health practitioners are concerned about how it might affect their ability to practice now and in the future.

“What we have most to fear is that this will establish a legal precedent that other insurance companies will follow,” declared Keith Gonsor, Ph.D., who is in private practice on Long Island.

Jacob Gershoni, ACSW, a New York social worker is also concerned.

“This is a very upsetting issue. The more I think about it and talk about it with colleagues, the more ominous it seems. It will set all kinds of precedents. If Oxford gets its way in undermining the essence of our work, other insurance companies will follow,” he said.

The American Psychological Association (APA) is also closely monitoring the situation.

Shirley Higuchi, J.D., assistant executive director for legal and regulatory affairs at the APA, said laws and regulations from all states were being scrutinized for relevance in the Oxford matter.

In a message to the PSY-USA listserve, Russ Newman, Ph.D., J.D., executive director for professional practice, expressed the organization’s concern about the legality of requesting repayment of fees based upon the claim that the psychologists’ record keeping is somehow inadequate.

Newman also is seeking all existing versions of the Oxford provider contract.

Mary Lou Bernardo, Ph.D. is a writer and psychologist in private practice in Connecticut.

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