Medicare Improper Payment Report for Behavioral Health Services (2016)

by  Wyn Staheli, Director of Research
September 1st, 2017

The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July 1, 2014 through June 30, 2015, was 89.0 percent. The estimated improper payment rate (claims paid incorrectly) was 11.0 percent which is a decrease from last years 12.1 percent rate.

As with most years, the biggest problem was the lack of documentation to support the services or supplies billed (64 percent of improper payments). It should be noted that although those numbers have decreased from last year, there is still room for improvement. Although not the worst offender, claims for behavioral health still score poorly on insufficient documentation as indicated in the table below.

Behavioral Health Provider Type Claims Error Report

Provider Type

2015 Improper Payment Rate

2016 Improper Payment Rate

Type of Error

No Doc

Insufficient Doc

Medical Necessity

Incorrect Coding

Other

Clinical Social Worker 29.8% 19.8%

4.4%

93.6%

0.0%

1.9%

0.0%

Clinical Psychologist 28.9% 30.3%

0.0%

96.7%

3.3%

0.0%

0.0%

Psychiatry 30.8% 24.0%

0.6%

69.7%

0.0%

29.7%

0.0%

Average for all provider types 29.8% 24.7%

0.2%

86.7%

1.1%

10.5.0%

0.0%


From this table, it is easy to see that the biggest problem is lack of documentation. For more information on documentation standards, see the Reimbursement Guide for Behavioral Health.


References:

Medicare Improper Payment Report for Behavioral Health Services (2016). (2017, September 1). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/medicare-improper-payment-report-for-behavioral-health-services-2016-31778.html

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