Telehealth provider found to have overbilled Medicaid

OIG auditors recently found a behavioral health services provider had billed the state incorrectly for add-on psychotherapy sessions, including the use of providers who were not enrolled in Medicaid. The OIG conducted the audit on PsyClinic for billing from June 1, 2021, through December 31, 2021, during which the company received $381,573 for 4,363 claims, including psychiatric evaluations, maintenance and add-on services. 

Although PsyClinic is enrolled in the state’s Medicaid program, four of the 11 health care providers that met with patients had not been approved to work with Medicaid clients. Of the 60 claims tested, 16 involved non-enrolled providers, resulting in $1,450 in erroneous billing. OIG auditors used this amount to extrapolate an error rate in PsyClinic billing of $54,087, which should be returned to the state. The use of providers not enrolled in Medicaid presents unnecessary risks to patients, including a lack of pre-enrollment screening by the state and the possibility that the provider is not approved to provide the specific service. 

Auditors also found PsyClinic had not identified whether the service provided was evaluation, management or add-on services for 57 of the 60 reviewed claims. Instead, they lumped all services provided into a single visit measured by the total time spent with the client. When a provider fails to identify provided services accurately, it creates difficulty in coding and evaluating the proper repayment for each visit. 

To remedy the discovered issues, auditors provided PsyClinic with recommendations to improve billing procedures and provide clients with Medicaid-enrolled providers for future visits. Specifically, PsyClinic should:

• Implement processes to ensure that:

1. Claims for services billed as time-based CPT codes are based on the actual length of services provided.
2. Medical records include documentation to support the CPT codes billed.
3. Medical records separately identify services provided.

• Verify its providers are enrolled in Texas Medicaid before they deliver patient services.