A helpful documentation checklist for prescribers
Here are the documentation and notes requirements you’ll want to remember as a prescriber.
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Compliance and documentation
Preparing for a chart audit
Understanding why audits happen, and preparing for a potential audit of your client records, can help you set your best foot forward.
Being a therapist involves a lot of behind-the-scenes work. Along with providing care to your clients, you’re responsible for staying compliant with applicable regulations — including the payers you work with, if you bill through insurance. To ensure you’re up to speed on all this — and to prevent fraud, waste, and abuse — insurance companies can conduct chart audits.
Getting asked to hand over your charts to an insurance company can be daunting, but it’s less scary than you might think.
“Audits aren’t always a red flag,” says Natalia Tague, a licensed counselor in Virginia. “They don’t necessarily mean you’re doing anything wrong.”
Understanding why audits happen, and preparing for a potential audit of your client records, can help you set your best foot forward.
Why do chart audits happen?
Chart audits — also called chart reviews — help to ensure clinical excellence and compliance with insurance standards and state and federal regulations, says Amanda Reagan, Headway’s clinical quality lead and a private practice therapist.
Ultimately, it’s up to the insurance company to determine when they’ll request records, but it commonly happens for a few reasons.
Sometimes, payers conduct a certain number of random chart audits each year (think of it as getting selected for the full pat-down in airport security). When you’re practicing in a way that might be outside what an insurance company sees as a “normative practice,” they may request your records to understand the justification for how you’re practicing.
For example, some payers audit all therapists with a certain number of clients on their caseloads, or therapists who frequently use certain higher-paying billing codes. You could also undergo a chart audit if you regularly see a client more than once a week.
“They may want to see what you’re doing to help reduce symptoms or the reason a person isn’t getting a higher level of care,” says Reagan.
It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.
Preparing for a chart audit
A few key steps can help set you up for success when it comes to chart audits. Of course, be sure you’re following all compliance components set forth by the payer and state and federal regulations for your license. For example, make sure you have informed consent before you conduct a telehealth session with a client.
Clear, detailed documentation of every session is another one of the most important things you can do to prevent audits and to prepare for one once your records are requested. Anytime you’re in network with an insurance company, go the extra mile to understand their specific documentation requirements.
“The more you can paint the picture of what your session looks like, the better you can mitigate any potential issues that might come up with a chart review,” says Reagan.
Reagan recommends including enough details that you can go back in several months and fully understand why you did a certain intervention or why you met with a client for as long as you did.
“That insight helps protect you as a therapist in terms of liability and malpractice but also ensures you have the capability of understanding from end to end what’s going on with the patient,” she says.
Key components of chart audits
Every payer has its own internal elements they consider during a chart audit. In most cases, Reagan says, companies request notes to justify the medical necessity of your treatment. This may include:
- Records request: You may be asked to share your electronic health records with an insurance provider for evaluations.
- Documentation review: Payers thoroughly assess your client records, including session notes, diagnosis and treatment plans, and consent forms.
- Compliance assessment: Payers will also want to ensure you’re compliant to state and federal or payer-specific regulations, including HIPAA.
- Ensuring quality of care: Auditors also review the care you provide to your clients, ensuring the modalities you use align with the current evidence base.
- Identifying areas of improvement: If the auditor found any deficiencies in your documentation, compliance, or quality of care, they’ll communicate these to you so you can better align with best practices.
You can better understand what each payer is looking for in your documentation, and the specifics of their auditing process, during your credentialing process.
“I always encourage providers to ask questions when going through credentialing to understand what payers are looking for,” says Reagan.
Headway is a free service that makes it easier and more profitable for therapists and psychiatrists to accept insurance.
Compliance and documentation
A helpful documentation checklist for prescribers
What is a biopsychosocial assessment?
Biopsychosocial assessments allow therapists to understand the most important components affecting clients’ mental health symptoms.
How to use the ASRS to assess ADHD
Learn more about the ASRS assessment and how you can incorporate it into your practice.