clinical social work association

Since the Affordable Care Act went into effect in 2011, there have been new forms of treatment reviews through Medicare called Comparative Billing Reports (CBRs).  They are designed to identify which LCSWs are considered “outliers” in psychotherapy practice; psychologists and psychiatrists are also receiving CBRs for psychotherapy.  This paper is designed to explain how CBRs are developed, what areas are being used in preparing CBRs, and offer suggestions as to how LCSWs may want to respond to them. 

There are several companies, called Health Information Handlers (HIHs), which create CBRs for the 14 Medicare Administrative Contractors (MACs) in the country, including CIOX, Ability Network, Chartfast, and others.  For more information see https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/Information_for_Providers .

As LCSWs know, psychotherapy treatment can take several months or even years of weekly psychotherapy sessions.  There can be great variation in the areas assessed by CBR companies.  These include 1) how frequently a patient is seen; 2) the average number of sessions for each beneficiary; and 3) how  long each session is/how much reimbursement has occurred.  For LCSWs, these areas are primarily determined by the diagnoses a patient has as found in the DSM-5, and the treatment methods the LCSW uses to treat these conditions.  For example, complex PTSD and complex grief can take longer to treat than adjustment disorders; cognitive behavioral therapy generally takes less time in treatment than psychodynamic psychotherapy. 

To find information on the three areas noted above, the HIH preparing the CBRs reviews all psychotherapy provided by providers for a given MAC.  All LCSWs are compared to all other LCSWs providing psychotherapy. Any LCSW who is in the top 10% in at least two categories, who sees at least 10 Medicare beneficiaries for psychotherapy, is sent a CBR notifying the LCSW. Additional documentation may be required to explain the reasons for the high level of service and/or reimbursement.  

There are numerous evidence-based psychotherapeutic methods which treat different kinds of mental health or substance use disorders.  It is safe to say that the majority of Medicare beneficiaries are senior citizens who qualify for Medicare based on age.  LCSWs who understand the senior population’s emotional difficulties are likely to specialize in this kind of psychotherapeutic work and see more Medicare beneficiaries. It would be a false dichotomy to see LCSWs who see a high number of Medicare beneficiaries as outliers; this is their area of expertise and practice. 

Another difficulty for LCSWs in the development of the CBRs is the comparison of all mental health conditions to all other mental health conditions.  As noted above, there are numerous mental health diagnoses, some of which take longer to treat than others.  Diagnoses should be “apples to apples” if these comparisons are being made.

Thus the LCSWs who are most likely to receive a CBR are those who see a large number of Medicare beneficiaries; who see these patients in long-term therapy; and who use 90837 more often than other CPT codes.  Long-term psychotherapy has been shown to have multiple benefits.   Some studies that have validated this point of view are:

• Studies that support a ‘sleeper effect’ for long term psychodynamic therapy in which there continues to be a course of clinical improvement following termination of therapy (Abbass et al., 2006; Anderson & Lambert, 1995; de Maat et al., 2009; Leichsenring & Rabung, 2008; Leichsenring et al., 2004; Shedler, 2010).   
• For patients with a broad range of physical illnesses, there is evidence that short term psychodynamic therapy decreases utilization of health care resources.  Abbass, Kesely, & Kroenke, (2009) did a meta-analysis of 23 studies involving 1,870 patients who suffered from a wide range of somatic conditions (e.g., dermatological, , neurological, cardiovascular, respiratory, gastrointestinal, musculoskeletal, genitourinary, immunological) and found a reasonable effect size of .59 in diminishing the severity of their health disorders.  Shedler notes a similar robust finding stating “Among studies that reported data on health care utilization, 77.8% reported reductions in health care utilization that were due to psychodynamic therapy – a finding with potentially enormous implications for health care reform” (Shedler, 2010, p.101). 
• With respect to more chronic mental health conditions, Leichsenring (2008) comments in this study that a considerable proportion of patients with chronic mental disorders or personality disorders do not benefit from short-term psychotherapy.  This meta-analysis showed that long-term psychodynamic psychotherapy (LTPP) was significantly superior to shorter-term methods of psychotherapy with regard to overall outcome, target problems, and personality functioning.  Furthermore, some cost-effectiveness studies suggest that LTPP may be a cost efficient treatment (Bateman, Fonagy, 2003; de Maat, Philipszoon, Schoevers, Deffer, de Jonghe, 2007).

CSWA hopes that this paper is helpful to LCSWs in understanding the CBR and responding to them.

Laura Groshong, LICSW, Director, Policy and Practice