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Medicare's Crackdown on Fraud Stirs Debate

Health: Rooting out questionable mental care billings saves $1 million a month in Southland. But critics say thousands of elderly and disabled people are hurt by restrictions.


A crackdown on Medicare billings for mental health care in Southern California that has saved about $1 million a month has thrown benefits into question for thousands of elderly and disabled people, and sparked a bitter battle over whether the savings are worth the human cost.

The 11-month-old effort is seen as a prelude to the coming national debate over how to curb spiraling Medicare claims. Both Congress and President Clinton have vowed to take up the Medicare issue during Clinton's final term in office. At issue is a campaign that Medicare launched last December, aiming to wipe out a rash of "egregious" billing abuses among mental health care practitioners here.

Concerned about the high volume of claims for psychotherapy in Southern California, defined by Medicare as the southern half of the state, the government had done an audit and was appalled at the results. In some cases, counselors who had done little more than show up to nibble cookies at a nursing home coffee klatch had billed Medicare for "group therapy." In others, psychologists had billed for more than 24 hours of therapy in a day, or for "sessions" with patients who turned out to be all but brain-dead.

But in its efforts to end the abuse and bring Southern California's mental health payouts into line with other states, critics say, Medicare has jeopardized beneficial therapy, disrupting counseling and forcing an increasing number of practitioners to drop Medicare patients. The situation has primarily affected the elderly, professionals say, but has also been painful and difficult for the chronically mentally ill, for whom Medicare has begun to question most forms of treatment beyond drug management.

"We're having to terminate abruptly with maybe 40 clients," said Mary L. Adams, director of HELP, a San Diego mental health care agency that is among hundreds of practices that serve Southern California's Medicare recipients. "These are elderly people, some of whom have no family or support system left. They are very isolated. And now they feel abandoned too."

"I support a crackdown on abuse, but I think they're throwing the baby out with the bathwater," said Joel R. Sunkin, a clinical psychologist in Downey whose practice includes a number of board-and-care residents who are schizophrenic.

"I have people who, when I started seeing them, were so depressed they would sleep to noon or 1 in the afternoon. Now they're up, they take walks, they take part in groups at the board-and-care home. One man who used to do nothing all day now goes to the library on his own. . . . The therapy does something drugs can't do. It can bring people back to life. To not give these people treatment is to destroy their hope of getting better."

But Alysson Blake, associate regional administrator for Medicare in San Francisco, said the restrictions have been a long time coming, and attributed the outcry largely to the fact that Medicare's administrators were so lax for so long with mental health claims.

"We don't want to be paying for services that are . . . not medically necessary," she said. "There's a limit to how much an insurer [is] required to pay, whether it's Medicare, Medicaid or a private insurer."

The controversy echoes the furor the managed care revolution has wrought among the privately insured. Eager to cut runaway health insurance costs, most companies have severely limited the amount and type of mental health care they will subsidize, raising a heated debate over what's necessary, what works and what's merely nice.

Until recently, that debate was not as immediate for the disabled and elderly, whose mental health care is paid for by Medicare. But in the last several years, Congress has been pressed to harness the rapid depletion of the Medicare trust fund, and that mandate has expanded the furor to the public sector as well.

The stringent reviews initiated in California are a preview of a model plan for inspecting psychiatric claims that medical directors for Medicare insurance carriers had been working on at a national level since early last year, officials said. The model was to have been tested at some point, they said, but the abuses here gave Medicare a chance to give it an early trial in December 1995. During the first half of 1995, Medicare was paying out an average of $5 million a month for mental health care in Southern California.

Medicare officials said that in the past several months, carriers in other states, including Florida and New York, have begun to implement reviews similar to the one going on in Southern California. They expect reviews to eventually be initiated nationwide.


Government officials said the concern about Southern California began about two years ago, when several families took a close look at some routine statements the government had been sending them about the care of relatives in nursing homes.

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