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.

Assessment Dilemmas and FAQ's

assessment dilemmas.jpg

Everyone does intake assessment a little differently. On one end of the spectrum we have clinicians who simply have clients sign a one page consent form and then dive into the client's ongoing struggles and then transition to a traditional therapy session. Not much discussion about policies, not much paperwork, and history on an as needed basis ongoing.

On the other end of the spectrum we have clinicians who use a structured intake document to gather biopsychosocial data and may use up to three sessions to complete this document and formulate a diagnosis. Lots of discussion about history, lots of paperwork and notes, and allowing plenty of time to evaluate symptoms as they develop.

And then a lot of us (myself included) are somewhere in the middle. 

Since you may be curious about my personal take on this, I'll share my own process here. But do please note that I often recommend people do things differently, based on their own practice and experience. It just depends on what works best for you

My assessment process

Personally, I use a structured form and ask clients to complete this form ahead of time. I do this for a few reasons:

  1. I get to read the client's description of their problem, strengths, etc. in their own words. I can then use this to build rapport more easily and it often gives me a better understanding of what's going on, even if we've already had a detailed consultation over the phone.
  2. It saves me time. Just as important as the above, I don't have a huge form to complete during or after the session! 
  3. It helps my memory. Since the form is mostly (if not all) completed I can focus on asking follow up questions, diving deeper into relevant topics or asking about things that may have been skipped. I don't have to worry about doing the whole thing or trying to write down important quotes or information in the moment.

I typically look over the form before meeting with the client and jot down a few notes to myself about further questions or things to explore. However, when the client arrives I first make sure they understood all the paperwork (which they typically sign ahead of time, as well) and review the relevant important things like limits to confidentiality. Then I ask them to tell me more about why they're seeking help at this time and go from there.

So, while I do start out fairly structured, I let things unfold once we have the formalities out of the way. Sometimes the topics we cover are many and sometimes we are much more focused. It really depends on the client. 

However, near the end of the first session, I do make sure to give them an idea about how I think I can help, how I work, and sometimes I will also give a potential timeframe. For EAP or insurance, this timeframe can be very important because it means we're already discussing how to best use our time together since it may be limited. I've found that clients really appreciate this open and honest communication and it helps them become more engaged. 

We will then review what we think our goals for working together are and move on from there. These things often change and that's okay, but after the first session I like for us both to have an idea about how we'll be working together and for the client to be thinking about how they can evaluate me and whether or not I'm the best fit to help them. 

So, that's my structured and unstructured assessment process! I get a formal intake document and a treatment planning discussion in there, but focus primarily on connecting with the client and learning more about their needs and goals.

Your FAQ's about assessment

So what is "recommended" or "best practice?" What works best for insurance? How much time do you need to spend on an assessment? Well, I get a lot of more specific questions like these and below I'm going to address them!

Continuing our FAQ series, below are questions from the QA Prep community about issues related to intake assessment. I do my best to answer these questions based upon my own experience but welcome your feedback below in the comments. Share your tips with us, as well!

"Because assessment is an ongoing process, how in depth are you when completing an assessment at the initial session?"

As I mentioned in my own process above, I am in-depth but only as it relates to the client's current needs. For example, if I am working with someone who is experiencing work stress and not being fulfilled at work, I often do not go into childhood history or past trauma. However, if the client is struggling with managing expectations at home and work because of a difficult relationship with their parents who also provide childcare, that may be a more relevant topic that we dive into.

Of course, we will always gather more information and continue assessing clients ongoing. That is a given.

However, the purpose of an initial assessment is really to make sure you have a clear understanding of the client's need so that you can adequately plan for their treatment. 

That means you want to have answers related to things like:

  • Whether or not you are within your training and expertise to treat this client's need/problem
  • What additional resources or collaboration may be needed (e.g. physician, psychiatrist, couples counselor, sobriety services, etc.)
  • For insurance, whether or not the client meets medical necessity criteria

So, I would say that I am in-depth regarding the "presenting problem" but not necessarily other topics. However, if you bill to insurance companies you may still need to ask other questions and this may limit your ability to be as in-depth, or may simply extend the assessment timeframe. I'll address these specific things below...

"Are there specific questions that must be in the intake assessment? How long should the assessment be?"

Yes, there are a few things I recommend every clinician review as soon as possible with clients:

  • Reason for seeking treatment
  • Goals for working together
  • Strengths and hobbies
  • Current living situation
  • Potential or past feelings/thoughts of suicidality or homicidality
  • Criminal history
  • Substance abuse history

The reason I listed the above things is that I believe these are all things that can become very important information very quickly, depending on the client's answer. For example, if you work in an office alone and sometimes work late at night you will want to know about any history of violent behavior from potential clients. Likewise, it is important to assess suicidality as soon as possible so that you can address this if it is a concern. 

I also think it is important to quickly assess the reason the client is seeking treatment so that you can make sure you are the best counselor to help this client, as well as make sure you provide referrals to additional resources in the community. 

Based upon your specific practice or population, you may also find other things are important to discuss initially. Decide on a structure and then stick with it for a certain length of time to see how it works. There have been quite a few times when I was tempted to leave a question out, thinking it did not relate to a particular individual, but was then surprised that it was quite relevant. So once you decide a question is important for your intake assessment, stay with it. Evaluate every 6-12 months to make sure the questions you ask are still relevant. 

You may also want to consider what has been helpful for you in the past or compare this with your own experience of being in therapy and what you liked about the first session or what you feel was missing.

Pay attention to your intuition and to any gut feelings. I have had a few experiences where I felt compelled to ask a question I don't normally ask and the ensuing conversation turned out to be extremely important. So, while I do encourage a basic structure, I think using your clinical judgement is paramount.

Lastly, for insurance clients (even those for whom you simply provide a super bill), I would add a few other things so that you directly address the important topic of medical necessity:

  • Identify the specific behaviors/symptoms that meet criteria for a diagnosis. Make sure to include how these manifest in real life, rather than simply listing off psychobabble terms like "insomnia," "anhedonia," or "hypervigilance."
  • Identify how these behaviors cause an impairment in the client's life. Make sure you can clearly link the diagnosis to a need you can address.
  • List any other treatment providers. If the client has an ongoing medical condition then you'll want to discuss whether or not collaboration is needed since this is often encouraged by insurance companies.

There are many other things to consider when your client is choosing to let insurance pay for their services, but these are the key things to include when you are assessing clients. 

"A client recently asked that I change her diagnosis from major depressive disorder to generalized anxiety. What should I do?"

Here we are talking about the ongoing aspect of assessment, as well as a legal and ethical dilemma. Firstly, a client's diagnosis should always be based upon their presented/reported symptoms. That is why it is important to include these symptoms/behaviors in your initial assessment, if you provide a diagnosis for clients.

To "under diagnose" or "over diagnose" or change a diagnosis without justification is FRAUD. Fraud is both illegal and unethical.

It's that plain and simple. In this particular circumstance, I would discuss with the client what their concerns are, how they came to this conclusion, and why they are seeking the change. I also find it helpful to educate clients about the concept of diagnoses and will sometimes review the DSM with them. 

Hopefully, this creates open communication as well as a better understanding about mental health symptoms and treatment, in general. 

Lastly, I also want to note here that I am not discounting the client's question. The client may actually be right! Perhaps they have not shared certain things, did some research on Google, and were able to read words that described their experience better than they could describe themselves. In that case, it may be justified to document this change in symptoms or new information and then change the diagnosis. 

The key is to constantly assess and to document your ongoing assessment and reason for any changes

So, let us know what you think about these dilemmas! Add your thoughts or tips in the comments below...

The Comprehensive Note Writing Guide for Therapists

I've written quite a few blog posts on notes over the past few years. Side note: In case you're feeling overwhelmed by the thought of blogging or starting something new, I never thought I'd have this much written by now! Keep at it and be consistent :)

Anyway... I wanted to put what I consider some of my best tips for writing notes all in one easy-to-find spot. Below are articles I've written here on QA Prep, as well as some other gems I've written for other people's sites. 

See what applies to you and check out the related article. Notice something you'd like to work on at some point in the future? Schedule it in your calendar now and bookmark this page so you can follow up when you have time to focus

Reviewing and improving your notes is an ongoing process. Don't feel like you have to do it all at once or learn everything right away. But if you don't schedule it and make that a priority, it's likely one of those things that will fall by the wayside. So take 30 seconds to schedule that time right now.

Let's dive in...

Questions to ask yourself when writing notes

It's always nice to have some guidance when sitting down to write notes. In this article I outline four questions you can post somewhere to ask yourself before writing notes. This helps to put you in the right mindset and keep the content something you can be proud of. 

Consider who may read your notes

There are actually many people who could potentially read your client's case notes. In this article I review the three people who are most likely to do so and how to consider what each may be looking for. 

Create your own notes template with check boxes

A lot of people ask me about creating check boxes for the notes in order to save time. In this article I outline a sure-fire process for doing this in a way that will still capture the individualized needs of your clients, as well as your unique ways of providing therapy.

Choose a notes template that works for you

Although I talk about some common notes templates in my free Private Practice Paperwork Crash Crash, this article gives you a quick read with similar information. I review four common notes templates and how they may apply to your counseling practice. 

Figure out how long your notes need to be

In this article I give you an example of both a short and long note and we evaluate what type of information we can remove in order to make things more efficient. This article is especially helpful if you feel like you write too much in your notes and want to cut things down.

Review your notes to see how you're doing

In this recent article I share some strategies for how to review your documentation. This is something I think is very helpful when you're feeling stuck with a client, as well as when you're ending treatment or writing summary letters. 

Write notes that make insurance companies happy

Notes don't necessarily need to be very different if you contract with insurance panels, but there are things you consistently need to think about with your documentation. In this article I outline the most important things to focus on if you think an insurance company may want to see your notes some day.

Identify ways to save time on notes

Most therapists are looking for ways to save time when writing notes. While I do encourage you to make documentation a meaningful part of the clinical process, efficiency is always a great thing! In this article I give you a variety of strategies for saving time on notes... and you can try out most of them right away.

Catch up on notes if you've gotten behind

It's a horrible feeling to get behind in your notes. Overwhelm takes over and it can be very difficult to find a way to catch up. In this article I share a five step process for catching up on notes, no matter how far behind you are!

There you have it! A comprehensive list of how to improve your notes and think about them a little differently. If you'd like more help with notes and documentation in general, you can check out my online workshop The Counselor's Guide to Writing Notes**. I love seeing how people's fear of documentation shifts after they can see some examples. 

You can also check out my ebook, Workflow Therapy: Time Management and Simple Systems for Counselors. It's a compilation of my best tips and blogs on improving your efficiency and managing all the paperwork related items in your practice.

So whether or not I see you online or in person, happy writing. 

**The Counselor's Guide to Writing Notes is now included with membership to the Meaningful Documentation Academy.

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. 


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.

3 Insurance Paperwork Reframes for Therapists


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 Psychology of Quality Improvement

You’ve probably heard the term “quality improvement” before but do you really know what it means? And what does quality improvement have to do with a private practice? Isn’t that just for big agencies and insurance companies?

I would say no, quality improvement relates to every therapist in every setting. It is often confused with it’s cousin, quality assurance. Quality assurance (in general) focuses on checking to ensure work is completed accurately and is usually a retroactive process.

QI Blog

On the other hand, quality improvement focuses on evaluating the effectiveness of work.This is totally relatable to therapists! As therapists, our work is often very subjective and intangible. It is difficult to describe the specific “outcome” of a particular session. Sometimes, it is difficult to put into words the level of intensity or resolution that occurred during a session. And while a client may feel better, more determined, or more clear after a session, they may have trouble telling a friend or spouse exactly what it is they “got out of” their therapy that day.

We live in a facts-based, results-oriented world. Clients want to know specific results they can expect to see. Family members want to “see change” very quickly (especially if they’re helping to foot the bill). Combine this with our digital era that emphasizes immediate gratification and the situation becomes even more challenging. 

Clients are looking up resources and researching psychological techniques ahead of time. A couple seeking therapy may ask you if you are a Gottman therapist. Another client may be specifically searching for DBT or exposure therapy. The term “archetype” is common language and clients are looking to see if your values match their goals.

Clients want to know treatment is researched, reliable and will give them the results they are seeking.These are the days of questioning long-term research on vaccines. People are not willing to simply “do what my doctor says” without something to back it up and an explanation from a professional they trust.

So, how can we address this in therapy? By using quality improvement techniques, no matter the size or resources in our practice. We can use more than attrition to evaluate a practice… without having to implement lengthy forms or lots of numbers. I recommend using your very own progress notes, assessment/intake forms, and most importantly, your client’s experience!

During your first session, talk with your clients and make note of the things with which they currently struggle. Take time to write those things down, especially in your first couple progress notes. Three months later, bring that up. Are those things still areas of concern? Have they improved and how so? Are these things still the focus of treatment or have you moved on to something else?

In our deep work with clients it is easy to get caught up in the weekly struggles and forget where our clients were just six months before. Quality improvement techniques encourage us to look at whether or not what we’re doing is effective and how we can improve upon it. More importantly, they keep you accountable to actively engaging your clients so they are part of the work and not just you.

You can easily use assessment or intake forms, progress notes and treatment plans to do this. If you have a ratings scale or questionnaire, even better! Pull out that intake questionnaire at week 18 and have your client complete it again. Compare and contrast the results. I guarantee you they will not have the same answers they did during your first session. And even if they did- you’ve now got some serious evaluation to do about why you’ve been working on something for 18 weeks with no subjective progress!

Most importantly, using quality improvement techniques creates buy-in from your clients. They’re able to put into words or onto paper what it is they’re experiencing after working with you. They’re able to focus on growth and see a tangible reward of all their hard work.

If you want to take a step further and implement a regular quality improvement plan as part of your group practice, look into my consultation service. I’ll work with your practice to see what makes sense and ensure you’re clear on how to improve.

Happy writing, everyone!

Why Medical Necessity is Important to Private Pay Therapists

Advice Help Support And Tips Signpost Showing Information And Guidance

In a previous blog I talked about the term Medical Necessity. Most of you are probably thinking, “Well, that only applies to people who work with insurance companies.” While it’s definitely crucial for people billing to insurance to understand those aspects, I think every therapist needs to have a good understanding of medical necessity. Here’s why:

  1. If your client has insurance and eventually wants to use that insurance for treatment, they will need to show they meet medical necessity. You can never predict if your client may choose to use their insurance. Even if you don’t plan to bill for them or continue services at that point, it will help them tremendously if you can give them (and maybe, their new therapist) an idea of how they meet medical necessity.
  2. Medical necessity is a term used in medical circles. As mental health professionals, it is important we are able to use the same terminology as medical professionals. We need to be able to speak the same language as physicians if we want to work with them in providing quality care and use them as a resource for referrals.
  3. Using the key points of medical necessity is a great way to conceptualize cases! Ethically, we need a clear understanding of our client’s needs and how we can help them. We also need a way to determine if treatment is effective and when it is no longer necessary. Additionally, if you have difficulty conceptualizing a complicated case, try using the medical necessity formula. It will help you narrow your focus. You can see the formula in my previous blog, What is medical necessity and why do I care?

Although private practice therapists are able to have a lot more flexibility in their documentation, using the concepts of medical necessity can help us to use consistent language as a profession and improve our communication with other practitioners, such as physicians. Rather than seeing the term as a box within which we are stuck, we can simply add the concept of medical necessity to our toolbox and resources list.

Are you interested in finding out more about private practice documentation? Sign up for the QA Prep mailing list and get immediate access to my free paperwork crash course.

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.