By Matthew Sexton, LCSW
A session can need 55 minutes for ordinary clinical reasons. Risk needs to be assessed. A disclosure happens late. Trauma work needs enough time to close safely. A family conflict cannot be compressed simply because a payer prefers a cheaper claim.
Yet the moment a session crosses 53 minutes, the claim changes from 90834 to 90837. The clinician has delivered three more minutes of care. The payer sees a different utilization category.
That gap is where the fight lives.
CPT 90837 is a time threshold, not a diagnosis
The coding rule is straightforward. Under the psychotherapy code structure introduced in 2013, 90834 covers 38 through 52 minutes and 90837 begins at 53 minutes (American Psychiatric Association). The correct code follows the service actually delivered and documented. It should not be selected because it pays more, and it should not be avoided merely because it may attract attention.
That sounds obvious until an insurer treats a high percentage of 90837 claims as evidence that a clinician is unusual. In 2017, the Ohio Psychological Association alerted members that Anthem and Change Healthcare were reviewing clinicians' 90837 patterns and asking for documentation supporting the longer service (Ohio Psychological Association). The mechanism matters: the payer can compare thousands of claims in seconds. A solo clinician must answer one chart at a time.
For a fuller coding walkthrough, read CPT 90837, 90834, and psychotherapy add-on codes. The short version is simple: record the actual time, make the clinical work legible, and never retrofit the clinical record around the payer's preferred code.
The pressure on the therapy hour started before 90837 existed
The code changed in 2013. The economic pressure did not begin there.
A peer-reviewed history of managed behavioral health reported that between 1993 and 1999, managed behavioral-health organizations decreased reimbursement for 50-minute psychotherapy by approximately 14% for psychiatrists, 14% for psychologists, and 9% for master's-level clinicians. Those organizations used care management and provider profiling while reducing private-sector behavioral-health costs by an estimated 30% to 48% (Frank and Glied review, National Library of Medicine).
The industry learned two durable lessons. First, psychotherapy could be managed as a unit of utilization. Second, clinicians fragmented across thousands of practices had less leverage than organizations negotiating for large networks.
Claims analytics made the first lesson easier to apply. Consolidation strengthened the second. The modern CPT 90837 audit sits on top of that history: identify the more expensive unit, compare its frequency, then move the burden of explanation onto the clinician.
Audit burden and bargaining power are not evenly distributed
The public conversation often implies that every provider meets the same insurer on equal ground. They do not.
In 2025, the Government Accountability Office reported that at least 47% of physicians were affiliated with or employed by hospital systems in 2024, up from under 30% in 2012. GAO concluded that hospital-physician consolidation often increased commercial prices and generally did not improve quality. It also described a basic contracting advantage: an acquired practice may gain access to the acquiring entity's higher negotiated rates (GAO).
A 2026 JAMA Network Open study gives us a view of 90837 inside hospitals. Researchers analyzed 8,517 negotiated prices across 980 hospitals and found a median price of $223, with an interquartile range from $155 to $382. Median prices also differed substantially by insurer (JAMA Network Open). That study is cross-sectional. It does not prove hospital ownership caused the differences. It does show that there is no single natural “price” for a therapy hour.
Platforms sell another form of scale. Alma says clinicians credential under its tax identification number to access enhanced rates (Alma). Headway says its team negotiates with health plans and keeps a variable percentage of session payments (Headway). Those arrangements may help a clinician reach contracts they could not obtain alone. They also move control of the contract to an intermediary.
The point is not that every hospital or platform wins. It is that scale changes the conversation. A solo clinician receives the policy. A large institution negotiates the policy.
Network data shows what low leverage costs patients
RTI International analyzed commercial claims covering 22 million people from 2019 through 2021. Patients used out-of-network behavioral-health clinicians 3.5 times more often than medical and surgical clinicians. For psychologists, the disparity was 10.6 times. RTI also found no improvement in the overall out-of-network disparity between 2013 and 2021 (RTI International).
That is not merely a clinician-pay story. When viable in-network work becomes harder to sustain, patients face thinner networks, longer searches, and more out-of-pocket expense. See therapy session rates in New York, New Jersey, and Connecticut for the practice-level math.
An insurer can save money on a claim and still make access worse. Both can be true.
The advocacy record is stronger than it looks, but fragmented
There are organizations pushing back.
In June 2026, the American Psychiatric Association and American Psychological Association Services sent Aetna a joint letter objecting to a plan that would pay 90837 at the same rate as 90834 for affected clinicians. They argued that collapsing the rates ignored the additional clinical time, questioned the transparency and parity implications, and asked Aetna to pause the change. Aetna later partially reversed the consolidation (joint letter).
The Psychotherapy Action Network has directly challenged 90837 audits and created an insurance issue tracker so clinicians can turn isolated experiences into a pattern (PsiAN audit advocacy; issue tracker). National NASW maintains clinical reimbursement resources, including 90837 guidance and advocacy about payer overpayment demands (NASW).
Illinois moved further. NASW-Illinois supported HB1085, and the resulting Public Act 104-0446 creates specific protections for medically necessary 90837 under covered state-regulated commercial plans beginning in 2027. It also targets disproportionate documentation and audit treatment (NASW-Illinois; Illinois Public Act 104-0446).
New York has not publicly matched that code-level approach. NASW-NY's published 2026 priorities address school social-worker ratios, loan forgiveness, paid placements, and unethical AI in therapy. The page does not name commercial reimbursement or 90837 (NASW-NY). That does not prove no private work is happening, especially during the chapter's recent organizational transition. It does identify a public agenda gap.
NASW-NY has a relevant history. It supported the 2018 parity reporting law, and New York Insurance Law §343 now requires reporting that includes network and reimbursement information (NASW-NY history; New York law). New York can see parts of the problem. The next question is whether professional groups will demand a remedy as specific as Illinois's.
A defensible 90837 record is clear, not enormous
Documentation should support care, continuity, and the service billed. It should not become a panic-written essay.
For a longer session, make five points easy to find:
- the actual start and stop time, or total psychotherapy time, according to your payer and professional requirements;
- the clinical focus of the session;
- the interventions used and the patient's response;
- why the work performed was consistent with the treatment plan and medical necessity;
- any plan, follow-up, or risk response that affected the session.
Then monitor the business record. Read remittance advice. Compare the code submitted with the code paid. Save payer letters and policy versions. Track recoupments and requests by plan, date, and stated reason. If several clinicians receive the same demand, aggregation is more useful than twenty isolated complaints.
Documentation cannot make an unfair contract fair. It can make the insurer state what it is actually disputing. VibeCheck.luxury is built around keeping the clinical record useful across the other 26 days of the month, while making the work of the session clear enough to withstand review. The goal is not more paperwork. It is a record that does more than one job.
What clinicians should ask their associations to pursue
“Support parity” is too broad to evaluate. A useful agenda would ask for specific protections:
- Cover medically necessary 90837 without automatic downcoding.
- Prohibit documentation rules that are more burdensome than comparable psychotherapy services.
- Prohibit audit frequency based only on a clinician's lawful use of 90837.
- Require notice before material reimbursement changes and disclose the methodology.
- Aggregate complaints and publish payer-specific patterns.
- Give clinicians a timely appeal route before recoupment becomes final.
Illinois provides a legislative starting point. The 2026 APA letter provides a payer-advocacy starting point. PsiAN provides a data-collection starting point. New York does not need to invent the issue. It needs to put the pieces together.
FAQ
Why does CPT 90837 get audited?
CPT 90837 represents psychotherapy lasting 53 minutes or longer and usually reimburses differently from a shorter session. Payers can use claims data to identify clinicians who bill it frequently and request documentation. A high percentage alone does not establish incorrect coding; the record still needs to support the time and service delivered.
Should I bill 90834 to avoid attention?
No. Choose the code that accurately reflects the documented service under current coding and payer rules. Deliberately selecting a shorter code for a longer service distorts the record and does not solve the underlying contract problem.
Is NASW advocating about 90837?
National NASW publishes reimbursement resources and older 90837 guidance, and NASW-Illinois actively supported a successful 90837 protection bill. NASW-NY's public 2026 priorities do not currently list 90837 or commercial reimbursement. That is a gap in the published agenda, not proof that no private advocacy exists.
What should I do after receiving a 90837 records request?
Read the request and contract carefully, preserve the original record, identify the dates and issue being reviewed, and respond through the required secure channel. Consider consulting your billing or compliance adviser, malpractice carrier, professional association, or qualified counsel when the scope or recoupment risk is significant.