Should I Use a Treatment Planner for My Notes?

I see a LOT of questions in Facebook groups about using treatment planners for writing therapy notes...

  • Which treatment planner is the most helpful?
  • Will a treatment planner make writing notes faster?
  • How can I use a treatment planner with my electronic health record (EHR)?
  • Will using a treatment planner help me avoid an insurance audit?

But I notice that people are asking a lot of questions without explaining what they really want to know. After fours years of answering questions about writing notes in private practice, I know what these counselors are really thinking. 

And what most therapists really want to know is this:

What tool can I use to make writing notes something I will no longer dread, be confused about, or spend hours of my time doing (or avoiding)?

The answer to that question is not something most therapists are happy to hear. Because there isn't just one tool or strategy that will solve that problem.

However, don't lose hope!

That doesn't mean you can't solve the problem. It just takes a little more effort up front and takes the time of setting up individualized systems that work best for you

When Treatment Planners are Helpful

Treatment and notes planners can be really useful when you have the right mindset about how to use them. Here are some ways they are most helpful:

  • When you're looking for ideas on what to write (for example, when you are experiencing writer's block or starting out with a new method/client)
  • If you need help checking your interventions and treatment plans against insurance requirements, since insurance does want you to clearly connect the treatment to the diagnosis
  • When you're just starting out as a new clinician and don't have much experience to reference
  • If you work in an agency setting where you see a variety of clients and may need to work with multiple diagnoses with which you are not immediately familiar

When Treatment Planners are NOT Helpful

There are also plenty of times that treatment and notes planners are not helpful, despite clinicians trying to use them for this exact purpose. Beware using treatment planners for help with notes in the following circumstances:

  • If you don't treat based on a diagnosis, since most treatment planners are diagnosis-based in their recommendations and ideas
  • If you are looking for interventions and strategies with specific clients, browsing a large treatment planner actually tends to become more overwhelming than helpful (it's counterintuitive, I know!)
  • When you're feeling stuck with a client, because usually you need to discuss this with the client or seek consultation and looking through a treatment planner will rarely give you the insight needed in these situations (here's what I often recommend instead)

Additionally, I find that when treatment planners are helpful it's because the clinician works primarily with one diagnosis and ends up using only the portion of the treatment related to that diagnosis. 

My Top Recommendations

You know I would never leave you without some practical things you can implement right away! So here are my recommendations for how to create your own supplement that can make writing notes more simplified and efficient:

1) Use what you already have.

Rather than buying a book with thousands of options you need to sift through, why not go through your own notes? This is the absolute best way to create a list of interventions and goals that are personalized to you and your clients. 

I go into this process more in depth in this blog post, but in a nutshell all you have to do is spend about an hour reviewing 2-3 client records. Write down the interventions you see most often, the ones that stick out as unique to how you work, and anything else that seems important to you.

Voila! You now have a cheat sheet you can use to create a checklist in your notes template and to help help with writing treatment plans.

Repeat this process for goals/objectives and you'll have another cheat sheet for creating treatment plans (you might have to review more files for this since we use the same goals for many months with the same client). Between those two cheat sheets you'll be able to create very customized treatment plans very efficiently!

2) Have prompts ready. 

One of the easiest things you can do right away is have some note writing prompts next to your computer (or wherever it is that you typically write notes). These questions will help get you in the right mindset to write notes and will help you focus on the things that really matter.

I have a list of note writing prompts available inside my free Private Practice Paperwork Crash Course so that all you have to do is sign up, log in and download your prompts!

3) Set a timer.

Have you ever heard of Parkinson's Law? This states that "work expands so as to fill the time available for its completion."

That means if you give yourself 20 minutes to write a note, it will likely take 20 minutes. And if you give yourself 10 minutes to write that same note, it will likely take 10 minutes! 

This can be anxiety-provoking at first but remember that if you do forget something major, you can always go back and add an addendum to your notes. So it's not the end of the world if you feel like the note is unfinished when the timer goes off.

Over time you'll get better at writing notes more quickly and will feel confident that you know exactly how much time is needed to complete your client paperwork.

4) Get support from colleagues.

I'll bet you didn't know that one of the best ways to feel better about writing notes is to have a colleague read them! Yup, it sounds scary at first but I've found that most therapists are actually doing a pretty good job with their notes. They've just never had someone to tell them this.

Inside the Meaningful Documentation Academy I encourage members to submit notes to me for review. I'll actually read their client note and give them direct feedback. 

But you can even do this yourself. Meet with a trusted colleague and review one another's notes as a quality review. Remove whatever identifying information you can and then spend some time sharing with one another what you liked about the other's notes and what pieces were missing.

Now take some action!

Share in the comments what you plan to do next so your notes can become more efficient, simplified and meaningful to the work you do with clients.

What I Learned (about paperwork) from the Road to Success Summit

I had such a great time putting on the Road to Success Summit in June and I learned soooo much from all the experts I interviewed. It was pretty cool to do the interviewing because that means I aaaalllll the content!

I knew the Summit would be helpful for therapists in private practice and my goal was to cover as many different areas as possible. But there was one thing quite obviously missing... a lesson on paperwork!

So, I thought I'd take this opportunity to highlight how your documentation relates to everything in your private practice. And if you're interested in an opportunity join the LIVE version of the Summit, click here to find out more.

Below are the lessons I learned from all the experts who participated, and how it relates to your paperwork:

Casey Truffo and being the CEO of your private practice

-Casey dropped some major knowledge bombs about business in general and has such an easy way of explaining things. The big thing I got related to paperwork was to outline everything you do. Take the time to write out your process so you can later improve, refine and duplicate when needed.

Kelly Higdon and integrating coaching into your practice

-Kelly talked about the differences between coaching and therapy. One of the big differences was the intention behind the service you plan to provide. You might actually be working on the same area (stress at work, for example) but choosing a different way to focus together. And that means, your paperwork will look different! Kelly pointed out that with her coaching clients she actually takes notes during the session and sends them the notes. I do this with my individual consultations as well. We cover a lot so this way the client can stay focused!

Keri Nola and using your intuition in your private practice

-Keri and I talked a lot about the finer nuances of using your intuition in every part of your practice. I think this applies to your paperwork, as well. Don't just include things because you feel you have to, think about how you'd like to write. Never seen something in someone's intake packet but feel led to include it? Then do so! Listen to your heart as well as your ethical guidelines.

Jo Muirhead and creating a successful money mindset

-Money was the topic of Jo's interview and we discussed a lot of the ways we misperceive things and sabotage ourselves by often avoiding the topic. I see a lot of therapists uncomfortable with money and that impacts client care. Because if you're not able to create a clear plan and decide how much you need to charge to sustain your practice, you'll end up reducing your rates out of fear (and often telling yourself it's really out of client need). However, if you have a clear plan that's represented in your policies then that frees you up to provide pro bono or discounted services to those who need it without feeling resentful

Camille McDaniel and adding clinicians to your practice

-Camille brought up some excellent points about hiring and planning ahead. One of things this highlights is being really clear about the conditions of employment ahead of time and also very clearly outlining any conditions of subletting your space. One example she brought up was making sure her subletter's clientele was similar to her own so there weren't potentially awkward situations in the waiting room. 

Rajani Venkatraman Levis and building your practice through community, not competition

-Rajani is one of my favorite people on the planet. That has nothing to do with paperwork but I just want you know how awesome she is. Anyway, Rajani talked about the power of reaching out to others for support, without worrying about whether or not they might be your "competition." It's so crucial to have regular access to some clinicians whose opinions you value so that you can receive feedback when needed. Changing your forms or not sure how to write something up? Call someone you trust so you can talk it through!

Roy Huggins and using technology to serve your clients

-If you know Roy, then you were not surprised that this interview was packed full of extremely useful info! He talked about how the internet actually works and why that means it's our job as a counselor/therapist to review with our clients any risks with technology. Make sure you have a statement in your informed consent about those risks and then document reviewing them with your clients.

Melvin Varghese and starting a podcast 

-Melvin shared some very practical steps for how to start a podcast, as well as the tools he uses for his own successful podcast. He also talked about monetizing his podcast recently and how valuable it has been for creating authority and networking with other professionals. How does this relate to paperwork? Well, do you have a place for clients to write down where they found you? This will help you to gear your marketing efforts toward what is working best. And maybe, that's a podcast!

Ernesto Segismundo and using video to promote your practice

-Okay, I'll be honest, it's difficult to tie this interview into a documentation lesson. But you know what? I think Ernesto really highlighted why video is such a powerful tool. What if you had a video on your website explaining your intake process, rather than just telling people to download forms? The more interactive and personalized you can make things, the more your clients will appreciate that effort. And boy, will it make you stand out as going the extra mile!

Kat Love and creating a beautiful website

-Kat shared insight into how to create a website that is appealing your clients. This is huge because you're competing with all sorts of distractions online. Since my focus is on making your documentation meaningful to both you and your clients, this really begins with your website copy and presence. Make sure everything flows together smoothly. Use a lot of casual language and pretty colors on your website but then have very stoic sounding forms that are all black and white? That's a mismatch! So continue your branding from website to forms to service.

Clay Cockrell and providing counseling online

-Clay provides counseling online and also runs a directory for other therapists who provide online services. Since this whole online counseling thing is so easy for him, he shared sooooo many resources and tips! One big tip? Create a plan for what you'll do when technology fails, because it will at some point. If you're providing counseling online, include this in your informed consent form or create a separate document that explains what you'll both do (for example, will you call the client or should they call you?). This can decrease any stress that may occur, for both you and your clients.

Barbara Griswold and responding to insurance inquiries

-In Barbara's interview we talked about dealing with insurance companies and she shared a lot of the mistakes she sees therapists make. One of the big things is thinking they don't need to worry about insurance ever seeing their paperwork. Although it's not super common for insurance companies to audit your files, it does happen. And the way in which you document can impact whether or not your client's services will be rejected. So, even if you're just providing a super bill, make sure you're well informed about what's needed.

Samara Stone and building a practice based on insurance

-Samara talked about why it's important for her to have a large practice that bills insurance and also shared some of the mistakes she made early on when using insurance. One of the biggest mistakes was being unfamiliar with the billing process. Once she decided to suck it up and learn what was needed she was able to make sure billing was going smoothly. And, that allowed her to know the right person to hire when she needed to outsource that task because of the time it was taking. 

Nicol Stolar-Peterson and creating a court policy

-In Nicol's interview I tried to start off with "what do we do when we get a subpoena?" and Nicol let me know we had to back up first! Why? Because responding to legal requests and whether or not you get paid to do so is all about what you have in your court policy. So make sure you've outlined that ahead of time and don't get caught losing money while waiting around in the courthouse just to assert privilege. 

Agnes Wainman and identifying your ideal client

-Agnes talked about why it's important to identify an ideal client and then actually walked me through some exercises to do that. But marketing isn't where this stops. Make your intake paperwork speak to your clients, as well. Continue that relationship from whatever made them call you to them completing their forms and walking in your door to the two of you working together. If your forms are personalized to their needs, they'll immediately feel a sense of relief for taking the step and reaching out to you. 

Allison Puryear and networking your way to success

-Allison and I talked about how you can choose networking strategies that are specific to your personality and work with your strengths. Wondering what to talk about when you meet with other therapists for networking? Ask them what type of notes template they use! Trust me, most counselors are actually interested to talk about it because they're dying to hear what you do, too!!

Stephanie Adams and creating systems that sustain your practice

-And we're back to where we started... with systems! Stephanie focused on the ways in which creating systems for her practice has saved her time and stress. One of the first systems I recommend you automate and really spell out is your intake system. How do you give clients info in the beginning, how do they sign and read forms, how do they pay you, will you remind them of their first appointment and when, etc. Writing this all out will save you a lot of stress in the long run.

If you didn't get a chance to watch all the interviews, then check out the interviewees who sound the most useful to you. They ALL have great resources to be used at different points in your practice.

Also, make sure you're signed up for my weekly newsletter so you never miss info on awesome stuff like this! I've got a few things planned coming up, including some live workshops across the U.S. You won't want to miss it!

What is a Notice of Privacy Practices?

You may have heard about a form called the Notice of Privacy Practices but not really be too sure what it's all about. In this video I'm helping to clear all that up! Click below to watch...

While the Notice of Privacy Practices is a complete form, the main aspects that apply to therapists in private practice include:

  • Your record keeping policies
  • Your client's access to records
  • How you share client information
  • Opportunities for clients to file a complaint

Healthit.gov provides an excellent sample form that is both visually appealing and covers all the necessary bases. Click here to view the sample. 

Remember that even if you're not a HIPAA covered entity, many of these principles are still considered best practice to include in your informed consent process. 

The key, as with everything, is to determine how these principles apply to your clients and use that for discussion. Let us know in the comments how you include these principles in your forms!

Why Insurance Billing is Like a Wedding: For every therapist who provides a super bill

Do you provide a super bill to your clients so they can be reimbursed by their insurance company after they pay you? 

You may think because you choose not to contract with insurance yourself that your client's records are protected. Well, that's only partly true. 

You see, when clients choose to allow their insurance company to pay for their counseling they are entering into a "deal" with the insurance company. They're essentially letting the insurance company call some of the shots related to their treatment. 

What does this look like? Well, that depends on lots of things but mainly on the insurance company and your client's plan. 

To give you a real world picture of how this plays out, let's look at this common wedding scenario:

Your parents offer to pay for the reception at your wedding. This is quite a large expense and you're very appreciative. In fact, you may not even have a reception if they weren't willing to pay. You graciously accept their offer and begin planning.

Things are going well. Your mother helped you choose the food and it's going to be delicious. You sit down with her one weekend to plan out the seating arrangements... and things take a turn. She has a different idea about the priorities and order of seating.

You may argue for a bit but in the back of your mind you know: she paid for this. Can you really just tell her no? How much say does she get? 

And think of the mother's argument for a minute... she has invested all of this money, very willingly. But she wants to make sure this expensive event will be "all that it could be." She may understand some dynamics the bride is unaware of or may have thought differently about her level of input from the very beginning. 

Insurance companies are similar in that they have a vested interest in your client's therapy. To put it frankly, they are "footing the bill" and they want to make sure they are getting their money's worth

Keep in mind this isn't necessarily a negative thing. If your client understands this process, is fine with it, and using insurance makes therapy more easily accessible to them, GREAT! 

But if your client doesn't understand that there are certain rules to follow and no guarantees about ongoing payment, this can be quite a shock. And it's my belief that it is your job to tell the client about this scenario.

You may be thinking, "but that's exactly why I choose to do the super bill thing rather than have a contract with insurance companies, so I don't have to think about this stuff!" Totally understood, and you're right. It's not your job to think about all the insurance requirements when you don't even have an insurance contract.

But it is your job to explain the limits of confidentiality. And as soon as you choose to provide that super bill, I believe it's your ethical duty to explain to your clients the realistic expectations to have with insurance, reimbursement and confidentiality. 

It doesn't have to be a long conversation! And you can phrase it many different ways... but yes, I do have some tips for what you can say... or you can just steal my wedding scenario.

  • Explain that insurance may limit things such as how much they're willing to pay per session or how many sessions for which they'll approve payment. Discuss what this means for the client as far as out of pocket expenses and expectations. 
  • Explain that once insurance is paying for something they have the right to follow up and see how things are going. This is typically either via phone or records request. 
  • Make sure clients understand if they choose not to allow records to be released when requested, insurance may choose not to pay for those services.
  • Inform your clients that any super bill or anything submitted to insurance related to payment will require a diagnosis. Discuss with them possible ramifications of this (like implications for life insurance coverage). Also let them know what their diagnosis will be, why and insure they understand that piece. Note: It is considered insurance fraud to inaccurately diagnose a client in order for them to obtain coverage. 
  • Stay focused on the part you know. Don't try to guess what the insurance company will or won't cover. Refer the client back to their carrier for questions related to coverage.

For many clients there are very few issues and things run smoothly, requiring little work on your end. But in those circumstances when requests for records or denials of payment come up, it's best to be prepared.

Let us know in the comments below if you have any further tips for explaining to clients the relationship between therapy and insurance. And feel free to share any resources as well. 

I have some on the QA Prep Resources page and you're welcome to ask questions below.

Insurance Documentation Made Easy (for Therapists)

Have you ever tried to research the answer to a question about insurance billing or documentation? You'll wind up with all kinds of resources that are often overwhelming.

Worse yet, ever post an insurance documentation question in a Facebook group? You're bound to get five different answers to the same question! 

Why does this happen? How come the answer isn't easily accessible?

Because each therapist provider has a different contract, with different stipulations. That means you and your therapist friend may each have a contract with Magellan but actually have different requirements for billing.

What's the takeaway then? Don't blindly follow someone's advice about your contract with the insurance company! Instead, I recommend you always contact the company directly to get the answer to your question (or read through your contract). 

Don't feel disheartened, though. There are a few things that are pretty universal in the insurance world. Those things are billing codes and the concept of medical necessity

And because I like to make things nice and easy for you, I have a nice little cheat sheet with common billing codes (CPT Codes) that counselors use. Click here to download the cheat sheet.

This cheat sheet is part of the insurance lesson in my online program, Meaningful Documentation. There are plenty of other cheat sheets you can find if you do a Google search but this one is very specific to the common codes therapists in private practice use. Plus, I give you a little description of when each code is used. 

Remember that whether or not you're actually allowed to use each code is dependent on your individual contract but this should help you determine what is needed and when.

I also recommend you hop on over to one of my previous blogs, Top 5 Things to Know About Insurance Billing, if you're new the insurance world or simply searching around for answers. This topic can become overwhelming very easily but that's not necessary!

Make sure you know your contract and understand medical necessity first and foremost. Then make sure you're using the correct documents (like a Notice of Privacy Practices) and sharing with your clients the limits to their confidentiality. 

Then keep doing the awesome work you do! And make sure you're on my email list so you get notices about other cool blog posts like this one ;)

Hope you find the cheat sheet useful and let me know how it goes! And happy writing.

Top 5 Things to Know About Insurance Billing

Insurance isn't so bad but sometimes there are very specific things that don't go over well with most therapists. Insurance thinks differently than we do. Unfortunately, when they're footing the bill it's up to us to learn their language rather than the other way around. 

In my last post I discussed when you should actually say "yes" to insurance. If you've already made that "yes" decision, there's still more you need to know. 

Today I'm breaking things down into the five most important things to know about insurance billing. Have these five things down and you'll be able to answer any clinical question that arises and be prepared ahead of time.

Know the company's definition of medical necessity.

Most company's definitions have similar components. These usually include a diagnosis (and the company may limit diagnoses that can be treated to a certain list), impairment in some area of life in which functioning was previously not impaired, and a clear treatment plan or treatment goals. Know this well enough that you can assess for medical necessity during your initial appointment and always keep this in mind when requesting sessions from insurance.

Be able to describe your client's diagnosis and how it impairs their functioning.

You must be able to described your client's diagnosis and how it impairs their functioning. This is key to explaining why your client's needs should be addressed through therapy rather than other means. Example: Client is on probation at work because he cannot focus and completes tasks late due to symptoms of depression. It is important to spell this out so it is clear the employment problems are related to a mental health issue rather than something else.

Be able to describe how therapy will alleviate your client's symptoms.

Be specific about the areas of life therapy can address. Ask yourself, "why is therapy better for this client than medication, coaching, or even talking to a friend?" You should have a clear answer for every client. Include theoretical techniques and evidence-based practices that work well for that specific diagnosis. 

Have a clear, short-term treatment plan from the outset.

The key to this is the phrase short-term! Insurance companies want to see that you have a clear and understandable treatment plan to focus on this individual's needs. They want to know exactly how long your treatment will take. This requires planning ahead so you know what you'll cover (for the most part) in the coming sessions. Of course, we all know other things may come up but the idea is to plan ahead and be prepared to stay on track as much as possible. Be very proactive!

Know the recommendations or requirements for consulting with other providers.

Some insurance companies would like for you to consult with the client's primary care physician, among others. This can have an obvious impact on treatment. Know what they require, what they recommend and how they'd like you to document that consultation. Ask about the frequency and expectations and make sure to discuss this with your client in an objective way once you're clear on your role. Side note: And yes, still get written authorization from your client!

I created these tips to be simple and easy to follow. If you'd like a pretty downloadable version, feel free to click here and save.

I know that many of you still have more specific questions. No worries! While I may be an insurance mole, I'm not a billing expert. But I know another therapist who is! Barbara Griswold has an excellent book available on this topic. If you're a counselor and plan to contract with insurance, this is a must-have. Click below to check it out:

And, as usual, feel free to post your questions or comment below! 

One caveat: Every provider has a different contract so an answer that may apply to one person may not apply to you. Be careful when interacting with others and assuming as such since you may unknowingly mislead someone.

Happy writing (and happy billing)!

When to Say "Yes" to Insurance

Insurance gets a bad rap. And there are plenty of legitimate reasons why... there's the limitation on number of sessions, the disclosure of client information, the limits on pay received and the extra paperwork to complete.

But sooooo many therapists actually do say "yes" to insurance. And while there are some who do it simply to fill up their calendar, there are plenty of others who do this as a conscious choice and as part of their business plan.

And they even feel good about it!

So how do you know if insurance is right for you? There are lots of things to consider. Here are some questions you need to answer before making that decision:

What is the reason you'd like to accept insurance?

You may have heard business coaches talk about being clear on your "Why." When it comes to insurance, I think this is really important. Are you joining a panel because you've heard crickets and want an "easy" referral source? Or perhaps you've been told a private pay practice is unrealistic. Or maybe you've worked with a lot of middle-class working people and want to provide a more affordable option for them. 

Figure out who you want to serve and whether or not being on a panel makes sense with the decision. It will also help you figure out which panels to seek out if choose to say "yes."

How much money do you need per session to make a living?

This is really important. I'm not the person to help you with a business plan but if you haven't created one, you'd better consider this before joining a panel! Many companies pay very little to Master's level clinicians and you need to consider if you can actually afford to accept that fee.

There is some strategy to this, as highlighting your special skills (like speaking another language or specializing in Eating Disorders) can impact your rate and will definitely impact your acceptance. Don't be afraid to negotiate. Think of it as an interview where you're highlighting the very best you can do.

Who will do your billing?

If you've been thinking you would just do all the billing yourself, you may want to reconsider. It's not impossible and some therapists have very little trouble with this. Others have a huge hassle. Unfortunately, there's really no way to tell under which umbrella you'll fall. 

But I will tell you it only takes a couple of denials to make the cost of a billing specialist worth their fee. These are professionals who agree to follow up on claims and denials so you don't have to spend hours on the phone trying to retrieve the $59 you're owed from three months ago. 

Barbara Griswold is the mental health insurance guru and she's put together a list of the best billing specialists. Click here to check it out. 

Will you have a limited number of insurance slots?

Perhaps your "Why" has made it clear to you that you want to accept insurance but your math has shown you that private pay will provide you better work hours. There can be a happy medium. You can choose to only have a limited number of insurance clients. It's just very important you make this clear in your contract and that you stick to this. 

Are you prepared for the documentation?

Most insurance companies actually don't have mounds of paperwork as part of the deal. I swear. However, you do need to be prepared for things like audits and calls from case managers. You need to be on top of your notes and have a clear treatment plan in place for every client.

Be honest with yourself from the outset so that you avoid frustration later on when the insurance company is requesting something you're not prepared to provide. 

Once you've figured out the answers to these questions you should have a pretty clear idea about whether or not insurance is for you. 

Do you accept insurance in your practice? Why or why not? I'd love if you comment below and let us know your own reasons... and lessons you've learned along the way. 

3 Big Problems Therapists Had in 2014

You know how your clients often get stuck coming in and talking about the same problem session after session? You review with them strategies you've previously discussed or you process why the same patterns seem to continue across relationships and circumstances. And, while every person is unique, you begin to see common themes emerge.

Well, in 2014 I started QA Prep because I noticed therapists asking lots of questions related to clinical documentation... and I started to see patterns emerge. The same questions, over and over again. And I thought, "what if I developed resources for therapists so they didn't have to search all over for answers?" I opened shop in April and spent a lot of time answering emails, responding to questions in Facebook groups and problem-solving over free consultation calls... and here are the main things therapists had problems with in 2014:

Time Management

Did you know the majority, yes the vast majority, of your colleagues struggle to keep up with their paperwork? If this is a struggle for you, you are not alone! This is one of the most common and one of the most destructive problems I see. When therapists think documentation is boring and meaningless, they avoid it or do sloppy work. And once you're behind by one day, it's easy to push things back further... and before you know it, you're a whole month behind on documentation. And then the paperwork to be completed looks like a huge mountain to scale.

The game of catch-up, fall behind, catch-up, etc. becomes a vicious cycle and creates a lot of resentment toward documentation. 

The key is really to be honest with yourself and create a realistic plan. Don't do what your previous supervisor told you worked for them or what the therapist down the hall is doing. Do what works for you! Some people choose one day per week to do all their paperwork, some do notes for every individual in the 10 minutes between sessions, some do notes for an hour at the end of the day. These are all possible strategies to try. The "best way to do paperwork" is whatever works to actually get it done. I would recommend at least creating a weekly plan so that by the end of the week you know everything is complete and don't have to catch up later. 

Insurance

I consistently get a lot of questions about insurance, relating to reviews by the insurance company, how to write notes and treatment plans for insurance, and what CPT codes to use for different sessions. Honestly, the CPT code questions are the most common and also the easiest to answer! Here are the top three...

Q: What code do I use for couples counseling?

A: For insurance and coding purposes there is no such thing as couple's therapy, there is family therapy. Use the family therapy code, 90847, when doing couple work and clearly identify why the marriage counseling is assisting the individual client with his/her mental health needs. This still requires the individual to whom you are billing insurance to have a diagnosis. 

Q: Does insurance cover teletherapy and what code do I use?

A: The answer is, it depends. Some states have required insurance companies to reimburse for telehealth services but some have not. Furthermore, the requirement does not set a standard for payment, meaning the insurance company may reimburse teletherapy at a different rate from your in person sessions. The key is to know whether or not your state is included in this list and to check your individual contract with the insurance company. If you are able to provide teletherapy, use the regular therapy codes with a "GT Modifier."

Q: Does insurance cover (insert service or code here)?

A: Again, the answer is, it depends. Every contract with an insurance company is unique, meaning the therapist in Suite A may be contracted to bill seven different codes/services at a specific rate and the therapist in Suite B may be contracted with the same insurance company to bill nine different codes/services at a different rate! This means the answer to any question about what you can bill lies in your contract. Do not rely on your colleague's experience in this area, make sure to look at your individual agreement. As a side note, this also means that yes, your rates are negotiable... if you want them to be!

Staying Up to Date

Lastly, another concern that is common is figuring out how the heck to stay up to date. Many therapists feel pretty competent in their documentation but after 15+ years in practice they are unsure whether or not they're up to date. Documentation is not a common topic to discuss, especially among seasoned clinicians, and it's easy to start feeling as though you may be missing something. 

The obvious is answer to this dilemma is taking continuing education classes, especially in areas such as ethics, HIPAA, and clinical documentation. Also, join your local and/or state professional association. Their job is to stay abreast of changes in mental health and update their members accordingly. Interestingly, I first heard about the 2013 changes to CPT codes from the California Psychological Association, not my agency or connections while working in quality assurance!

However, another great way to stay up to date is through consultation with colleagues. Choose a trusted colleague and discuss one to two cases together and how you do your paperwork for that case. Better yet, choose a colleague who has recently attained their license and then another colleague who has 15+ years experience. You can also review 1-2 of your client files ahead of time and come with questions. It's a great learning experience and you'll likely gain a few helpful tips from one another!

If you're not sure how to get started with a consultation group, sign up for my monthly newsletter (and get immediate access to my free Paperwork Crash Course), where I review tips on this and other ways to improve documentation. I take a totally judgement-free approach in all my material and I'm always creating new programs for therapists who want rock solid documentation. 

Share in the comments below any other struggles you think are common and we'll problem-solve together!

Like the tips in this blog post? This blog is part of the compiled tips in the ebook Workflow Therapy: Time Management and Simple Systems for Counselors.

The Insurance Mole

I have a secret I’m going to confess to the world right now- I was trained as a peer reviewer for insurance companies. That’s right. Those people (commonly known as a care manager or peer reviewer) who call you to talk about why your client needs more sessions.

Don’t hate me!

The truth is, I was trained but then I never got any peer review cases and the job just sort of fell off. So no, I never actually questioned why a therapist hadn’t justified medical necessity or denied sessions to anyone. But through that process and my experience working as a Quality Assurance Manager I’ve learned quite a bit about documenting for insurance.

Contrary to popular belief, insurance isn’t always out to get us and refuse paying for services (not all the time, anyway!). Think of insurance companies as a slightly OCD relative who maintains a very strict schedule and throws a tantrum when you want to make changes to vacation plans on the fly. They like their schedule and they’re sticking to it… unless you give them a good reason not to. 

You see, insurance companies work with millions of customers, so they have a lot of data. They’re able to see the average number of sessions people normally attend to deal with various problems or to work with certain diagnoses. 

They also rely on research. They know what type of treatment is proven to alleviate certain symptoms and what treatments work more quickly or have longer lasting results.  

Insurance companies then use that information to determine medical necessity, essentially,  whether or not a treatment is needed for a specific client, appropriate to the diagnosis/symptoms, and determine it’s effectiveness over time. (To learn more about medical necessity, read this past blog) They have a game plan. And when you sign that form to contract with an insurance company, you agree to play the game.  

So, the big question is whether or not you can all (therapist, client, insurance company) play the game and achieve a win-win-win. My answer is a modest yes… if you play by the rules and learn to woo peer reviewers every once in a while.

First, know the insurance company’s definition of medical necessity. As a peer reviewer, that was the first thing I looked at. Look at how your treatment fits into that definition. Write it out in a simple sentence or two, like a mini treatment plan. If you need more than two sentences, you’re getting too in depth for (most) insurance. Use concise language and be direct.

Second, evaluate the two biggest concerns of every insurance company- cost and effectiveness. Show the insurance company you’re not trying to squeeze every last penny out of them. You just want to do what’s best for your client. When talking with a peer reviewer, identify the progress you’ve already made. This highlights the effectiveness of your treatment. Then identify a clear plan for completing treatment. That may be two weeks or two years from now, but you need to show you’re thinking about the end result.

Ultimately, I was told that if a therapist could explain to me how the services were medically necessary and would help the client, I could recommend they were approved. However, I was only supposed to give a therapist about 15 minutes to do this, ask follow-up questions and make my recommendation, which is why I emphasize learning to be concise. 

Insurance companies feel like big bullies sometimes but remember that when you’re on the phone with a representative, care manager or a peer reviewer you’re just talking to another person. Treat them with respect, listen to their questions, ask them to clarify and know that they are working within the rules of the game as well. And the goal of the game is to get your client the best treatment they need and get them well as soon as possible. Hopefully, that’s something we can all agree on!

Still have questions about documentation and insurance? Check out Barbara Griswold's website. She has a regular newsletter and fantastic resources.

Top 5 Paperwork Resources for Therapists

TOP 5

You became a therapist because you love helping people, not because you love paperwork!

Likewise, I got into quality improvement because I love helping therapists make their paperwork more manageable. Through my years of teaching therapists I’ve acquired a list of places I commonly go for answers, ideas, and inspiration. I’ve compiled five of them that will help you with starting out your practice and getting continued support:

Ethics Codes for Paperwork

While very similar, each discipline has their own ethical requirements for completing and maintaining records. These are basic guidelines for your profession and do not include state laws or HIPAA regulation. I recommend you start here because the principles are easily accessible and brief. Then, seek out laws specific to your state or recommendations from your state’s licensing board or professional association. HIPAA is a whole other deal… I’d encourage you to check out Zur Institute’s online courses specific to HIPAA if you want that information specifically.

Private Practice Paperwork Crash Course

Yes, I’m going to toot my own horn for just a minute. I created a crash course on clinical documentation. In a series of videos sent out over a one week period you’ll learn tips on administrative forms, writing assessments, treatment plans, progress notes and billing to insurance. My goal with this mini course is not to give you forms to copy. Rather, I want to help you gain the mindset and skills to write quality documentation that’s less time-consuming and makes you feel confident for years to come!

The Documentation Sourcebook

This book has a ton of sample forms and a very affordable price tag! It is very detailed but don’t let that scare you. Use the forms as a starting point and pick and choose what you like. They are based mostly on insurance billing so if you have a private pay practice you can overlook a lot of the details.

Private Practice from the Inside Out

Tamara Suttle provides a multitude of practice resources on her website. She has an extensive blog where she frequently highlights experts in specific areas. This includes articles related to client records, HIPAA, insurance and other topics. She’s also super friendly and responds to comments and questions on blog posts with record timing!

Zynnyme’s Insurance Outsourcing Video

If you decide insurance billing is for you then one of the most important things you can do is outsource your billing to an expert. It only takes one problem claim to eat up 10 hours of your time and a large chunk of your profit. Check out this blog interview posted by Kelly and Miranda from Zynnyme where they interview Tiffany, owner of a medical billing company so you can see what it’s all about.

I hope you find these resources helpful. There are lots more out there but I think these are some of the best. What other resources do you use? Leave a comment below so we can continue building our resource lists!

3 Insurance Paperwork Reframes for Therapists

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Many therapists are frustrated with insurance coverage of mental health services. They are unhappy with having treatment decisions critiqued, (often but not always) receiving a lower fee than for private pay clients, and needing to submit specific forms for documentation.

These concerns (and many others) are all certainly valid and dissuade some from even dealing with insurance at all. Others begrudgingly choose to bill to insurance because they don’t feel their practice could be full with only private pay clients.

However, many therapists feel insurance is an important part of their practice. Some therapists even view insurance slots as their “sliding scale” slots and account for this in their business planning. I like this way of thinking because it provides the therapist with a positive mindset and reduces resentment toward the insurance company.

So, let’s continue with the positive thinking! Here are some common thoughts that pop up regarding insurance along with positive reframes for thinking about your paperwork and it’s relationship to insurance billing.

“I can’t believe insurance wants to look at my client’s (treatment plan, diagnosis, etc.)! Why won’t they just trust me to do my work?”

–Reframe: I’m so glad my client can receive quality therapy at a low cost to them. I’m glad there’s someone checking to make sure I’m doing my job well.

“Insurance pays such a small fee for my sessions!”

–Reframe: I’m glad I can use this hour to give back to my community by offering a service at my lower rate.

“I have so much paperwork to do for this community clinic!”

–Reframe: I’m thankful that community clinics are able to provide services for much longer timeframes than most insurance companies will compensate for. Unfortunately, that means I have a lot more paperwork to justify their extended treatment.

Notice that I’m not denying the truth in any of the more “negative” statements. Insurance does often pay lower rates than private pay. Insurance does require a certain level of documentation and often scrutinizes that documentation and/or treatment. However, these things are not necessarily bad in and of themselves.

I encourage you to carefully evaluate what thoughts came up for you around billing to insurance. Did you “poo-poo” my positive reframes? If so, I would question whether contracting with insurance is right for you. It’s certainly NOT for every therapist! And you know what? That's okay!

The decision to accept or deny insurance should be part of your business plan and in line with your professional goals. Know that insurance does require a much different level of documentation and oversight than regular private practice. It doesn’t have to be scary or overwhelming… but it will be if you have a negative mindset.

If you’re 100% sure you want to bill to insurance, sign up for my Private Practice Paperwork Crash Course. In a week’s worth of emails I review all the necessary documentation for private practice… and the last lesson is all about billing to insurance.

My goal is to help you make peace with documentation. If you still have any burning questions, leave a comment below and we’ll figure it out together. If you have your own reframes, feel free to post them here and share with your colleagues. Happy writing!

The Mountain of Paperwork in Community Mental Health

Mountain of Paperwork

Clinical documentation- mention it to most therapists working in community mental health and they will cringe. Along with that word comes mental images of being flooded with redundant paperwork, staying late to write progress notes (or worse yet, working from home), and having supervisors identify endless corrections needed. Few clinicians or supervisors will tell you they enjoy this aspect of their job. Fewer still will tell you they felt prepared for the demands of government-contracted requirements through their training in graduate school. Yet, ask any therapist with a client who has attempted suicide and they will tell you (perhaps begrudgingly) this is one of the most important aspects of their work. 

Clinical documentation is invaluable when we need it most. Progress notes document our efforts to contact clients exhibiting high risk behaviors. Consultation notes document  standard of practice and a rationale for our actions when “grey areas” appear. Mental status exams and assessments document the client’s history of symptoms and provide a course for treatment. Clinical documentation is a necessary tool for therapists working in the revolving door of community mental health. 

However, many therapists find the paperwork difficult to maintain. They don’t see the connection between the clinical work and the forms they’re required to complete. They feel drained and overwhelmed by the daily paperwork requirements. 

If you are a clinician working in community mental health and find yourself becoming overloaded with paperwork, try following some of these steps:

  • Prioritize your paperwork according to it's importance.
  • Talk with your coworkers to see what tips they find useful.
  • Do your best to keep interactions with your coworkers positive.
  • Decide from the beginning that you will NOT fall into the trap of “fudging” the time you bill by 10-20 minutes here and there.
  • Be honest with yourself regarding your strengths and weaknesses.
  • Engage in self-care.
  • Stay connected with your colleagues.

Make sure you talk with your supervisor from the beginning about your struggles to get the support you need. Seek out extra training and consultation. Your agency may offer refresher trainings or, if you’re in the L.A. area, you can check out the upcoming workshop I’m doing on documentation (trust me, I try to make it as fun as possible!). You can also sign up for the QA Prep Newsletter (and get access to my free paperwork crash course) to get tips on making documentation easier and more relatable. 

Don’t be afraid to evaluate different job options if you find you’re a round peg trying to fit into a square hole. When you’re less stressed, you’re providing better care for your clients. Keep the focus on being the best therapist you can be- in all aspects of your work and don't be afraid to ask for help when you need it. Happy writing, everyone!!

What is Medical Necessity and why do I care?

Medical necessity is a term used by insurance companies to determine if a client needs services, and what services are appropriate. If a client “meets medical necessity” then services are approved! If not, you get that dreaded denial letter. Each insurance company has their own definition of medical necessity, but there are usually three main components:

  • Diagnosis
  • Impairment
  • Treatment Plan

Diagnosis- Most insurance companies want to see a DSM diagnosis for clients to quality for treatment. It is not enough to randomly list a diagnosis (and also not ethical). You need to identify the client’s symptoms to show they meet the DSM criteria.

Impairment- People can live with a diagnosis and not really have an impairment. But, when symptoms start affecting a person’s work or personal life, they need treatment. An impairment is an area of life that is negatively impacted by the client’s diagnosis. Example: The client is depressed and has low motivation and difficulty concentrating which impacts their ability to complete tasks at work and they are now on probation.

Treatment Plan- We’ve identified that the client needs help. Now, what are we going to do about it? It’s the therapist’s job to show the client and the insurance company how they plan to help. Will you introduce certain topics or coping skills, will you use an evidence-based practice, etc. Check with the client’s insurance company, because you may need to identify how many sessions you think this will take.

Medical necessity is a great way to conceptualize your client’s needs and how you can use your expertise to help. If you’re billing to an insurance company, it’s a requirement. If you still need help, sign up for Maelisa’s newsletter and check out QA Prep’s Facebook page for more helpful tips.