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Articles: Safety plans critical for suicidal patients &
Psychiatrist to return $1.1 million for not complying with Medicare regulations  {Below}

Safety plans critical for suicidal patients
Samuel J. Knapp, Ed.D., ABPP

Psychologists need to develop safety plans when treating suicidal patients. Safety plans are brief, collaboratively written plans that involve several steps patients can take when they feel a suicidal crisis coming on.
The steps of a safety plan include:

Psychologist Session

    ·  Identifying patient-specific signs

        warning of an impending suicidal


    · Restricting patient access to

        lethal means.

    · A listing of activities that distract

        patients from their suicidal


    · Names and contact information

        for supportive people to whom

        the patient can talk.

    · Emergency contact information,

        such as the patient’s psycho-

        therapist’s phone number or a

        national suicidal hotline (988,

        starting July 16, 2022).

   Some psychotherapists may discuss restricted access to lethal means independently of the safety plan, but they should, nonetheless, conduct lethal means counseling with all suicidal patients.

    Patients can use their safety plans when they feel a suicidal crisis coming on. If patients fail to reduce their distress by engaging in distracting activities or talking to supportive friends, they can contact the professional resources listed in their plans.

    Safety plans can be brief, and some even fit on three-by-five-inch cards patients can carry with them. Plans can, and should, be updated as needed. Effective safety plans depend heavily on patient input.        

    As author Rory O’Connor tells psychotherapists, “A safety plan is someone else’s plan, it is not your plan.” When finishing the plan, Craig Bryan and M. David Rudd recommended asking patients to rate the likelihood that they would follow the plan on a scale of one to 10. If patients rated the likelihood that they would follow the plan as low, then psychologists can ask their patients how to improve it. Safety plans tell suicidal patients what they can do to reduce their distress. In contrast, no-suicide contracts — prewritten legalistic agreements not to kill oneself — only tell patients what they cannot do. Safety plans reduce suicide attempts by an average of 43% and should be used with suicidal patients. No-suicide contracts do not reduce suicide attempts.

    Safety plans are considered part of the standard of care when treating suicidal patients. If a patient dies from or, was injured in, a suicide attempt, a malpractice court might scrutinize the conduct of the psychologist.

    In determining if psychologists failed in their obligations to their patients, courts would evaluate the conduct of the psychologists according to the standard of care, which asks whether the psychologists acted like reasonable psychologists would have acted under similar circumstances. Courts do not expect psychologists to prevent all suicides, but they do expect psychologists to deliver services consistent with professional standards.

    In determining the standard of care, courts would rely on the testimony of experts with opinions informed by texts, scientific evidence and the consensus of other experts in interpreting the evidence.

    Because of the substantial evidence supporting the effectiveness of safety plans, and because of their wide acceptance among national experts, experts would likely testify that safety plans are part of the standard of care when treating suicidal patients.

    Of course, psychologists may have to adjust how they implement the standard of care depending on the totality of circumstances. Therefore, one could envision unusual circumstances when psychologists would not use a safety plan, such as if patients had cognitive deficits, were in a psychotic episode or were intoxicated. Or one might envision circumstances in which psychologists would modify the format of the safety plan, such as deleting the step of talking to a supportive friend, if the patient could not identify any such friend.

    Because safety plans save lives, involve patients in all aspects of their development and are minimally intrusive, they are considered a good risk-management strategy. Prudent psychologists will keep a copy of the safety plan in the patient’s chart, along with any revisions.

    They will document any unusual problems or modifications in creating the plan, including the clinical reasons for the modification.

References available from author

National Psychologist CE Quiz

Samuel Knapp, Ed.D., ABPP, is retired as the director of professional affairs for the Pennsylvania Psycho-logical Association. He has written extensively on professional ethics, ethical decision making, risk management and suicide prevention. His email is:

Psycguatrust ti retyrb 1.1 million

Psychiatrist to return $1.1 million for not complying with Medicare regulations

By Paula E. Hartman-Stein, Ph.D.

    The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently released a 38-page report of an audit estimating more than $1.1 million in over payments for psychotherapy services made to a Queens, New York psychiatrist,

one of the highest reimbursed individual Medicare providers in the country.

     The OIG analyzed documentation for 100 days of service sampled from April 2018 through August 2020 and that included both in-person and telehealth psychotherapy services. The psychiatrist under scrutiny owned a practice offering a variety of mental health services provided by herself, four licensed social workers with masters’ degrees, a registered nurse and one social worker, who was not a Medicare provider.

    The OIG determined the size of the over payment based on multiple deficiencies in documentation of the psychotherapy services. For example, the audit indicated treatment plans did not comply with Medicare requirements in 100 of the sampled cases. “Without a periodic summary of goals, progress towards goals and an updated treatment plan that described any improvement in the beneficiary’s condition, the clinician would not be able to determine whether the services provided were necessary, had a reasonable expectation to improve the beneficiary’s mental health or made progress towards goals,” according to the OIG.

Other deficiencies included undocumented start and stop times for face-to-face services, or total time spent on psychotherapy, having an unlicensed or unregistered therapist in New York State providing treatment and treatment plans that were not signed.

    During the COVID-19 pandemic, the Center for Medicare and Medicaid Services (CMS) has allowed telehealth services performed by a non-physician practitioner as an integral, though incidental, part of the service of a physician for diagnosis or treatment. The so-called “incident-to” service was to be supervised using real-time interactive audio and video technology.  Face-to-face incident-to services require that the

physician be physically present in the same office suite and be immediately available to

give assistance if needed. The audited psychiatrist was unable to show evidence that all

incident-to services were directly supervised. The report repeatedly stated that the

psychiatrist did not have compliance policies and procedures in place as mandated

by Medicare, and she did not provide adequate training to her therapists.

    One element of compliance requires that providers show “reasonable diligence” to periodically

review Medicare payments to determine if any over payments are made in error during a six -year

look back period. Over payments are to be returned within 60 days of discovering them. This is

known as the 60-day rule.


Reasons behind audits and method used

    The OIG conducts audits and reviews because it is mandated by statute to protect the integrity of the Department of Health and Human Services by reducing waste, abuse and mismanagement of funds, as well as to protect the welfare of its beneficiaries. In 2019, Medicare paid approximately $1 billion for psychotherapy services provided across the country. Prior OIG reviews found that Medicare had improperly paid millions of dollars for psychotherapy because the services did not show medical necessity, were billed incorrectly, lacked adequate documentation or were provided by unqualified therapists. This audit did not provide an opinion as to whether psychotherapy services were medically necessary.

    The OIG reported it conducted the audit of this psychiatric practice using generally accepted government standards. The sample consisted of 15,559 beneficiary days, from which a random sample of 100 days were sampled. Office of Audit Services (OAS) statistical software (i.e., RAT-STATS) estimated through an extrapolation process the amount of Medicare over payments.


Provider’s response

    The law firm of Kirschenbaum & Kirschenbaum, located in Garden City, New York, initially represented the psychiatrist and replied that the over payment amount is “inaccurate, unwarranted, or at the very least, grossly overestimated” and that a majority of the claims complied with Medicare requirements.

    After reviewing the psychiatrist’s explanations, the OIG reduced the number of deficiencies about non-compliance of incident-to requirements for three sampled days because the psychiatrist submitted patient sign-in sheets indicating she was present in the same office suite at the time of the service. However, other deficiencies were found. The OIG maintained its overall findings were valid and did not change the recommended recovery of over payment. A final case determination is unknown.

    The OIG recommendations for this case are not the final Medicare determination. Through a regional Medicare contractor, CMS will decide whether over payments exist and the amount required to be paid back. Providers have the right to appeal through a five-level process. The return of over payment is not required until after the second level of appeal.

     The current status of this particular case is unknown at press time.  Attorney Samuel Atlas from the firm of Kirschenbaum & Kirschenbaum said his firm was no longer representing this New York practice. He offered no additional comments.


Implications for psychologists

    Deficiencies noted in the case of this audit of a New York psychiatrist highlight requirements for all psychologists and social workers who offer psychotherapy to Medicare beneficiaries. For example, every practice under audit, including solo practitioners, is likely to have a better outcome if a written compliance plan is in place.  Group practices need to offer periodic training for their providers to understand current Medicare requirements. In documenting psychotherapy, all practitioners must include treatment plans, sign each therapy note and note start and stop times and total time spent with the patient. Although not included in this particular audit, documentation of medical necessity is another requirement often examined in Medicare audits.


    The complete OIG report and provider’s response can be found at:

National Psychologist CE Quiz

Paula Hartman-Stein, Ph.D., is a consulting psychologist and Medicare correspondent for The National Psychologist, who offers seminars and educational resources on best practices for documentation, compliance plans and ethical billing practices. Her email is:

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