Skip to main content
Headway

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.

August 16, 2024 • Updated on August 29, 2025

5 min read

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.

Practice in-network with confidence

Simplify insurance and save time on your entire workflow — from compliance and billing to credentialing and admin.

Talk to a practice consultant

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.


Reduce your risk with Headway

Headway helps providers stay audit-ready with our streamlined platform and designed-for-compliance notes templates. Reduce your risk while getting our support with insurance credentialing, billing, claims, and more.

Talk to a practice consultant

This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

© 2026 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.

Compliance and documentation

How to write progress notes

Progress notes are the core piece of documentation a provider should write after each client session, but it’s more than just a record of what happened.