Insurance Records Requests: Rules to Remember

Here’s a question I get all the time:

Can insurance companies request my therapy records?

Sometimes it’s asked a different way:

Do I have to submit therapy records (including progress notes) if an insurance company requests them?

>> This applies to anyone whose clients use insurance to pay for treatment, and that’s often what mixes people up. So for those of you who submit superbills, this post is still for you. Keep reading (or watch the video below).

The answer, in case you’re wondering, is YES.

If an insurance company is paying for counseling or therapy, they can absolutely request records. They can request the entire record if they want, they can request copies of notes, they can request a summary—it runs the gamut. They can ask for as much or as little as they want.

The pushback I hear from therapists is that it feels wrong, or it feels like an injustice, because we are worried about client confidentiality. That’s a valid concern!

However, what we as therapists need to address, is that it is part of our job to know a request for therapy records is a risk when clients use insurance to pay for counseling, and therefore it is our job to inform our clients of this risk.

So as soon as you contract with an insurance company, you need to make sure that your intake paperwork and everything you go over with clients includes this information:

  • Insurance companies can request therapy records

  • You can talk to the insurance company and give them basic updates

  • Insurance requires a mental health diagnosis for treatment to be covered

Then you need to make sure you’re covering that info with your clients in person.

Making the very real possibility of records being shared will often push clients to pay for therapy themselves rather than use insurance, because they realize they may not want their insurance company to have access to all that information.

It’s also important that you tell your clients that you are required by insurance to provide a mental health diagnosis, so they know they will have a mental health diagnosis on their record, and their insurance company will know that.

And I cannot emphasize enough how important it is to know that if you aren’t contracted with an insurance company, but your clients sometimes request their superbill to send over to their insurance company themselves, you still need to be having the conversation about potential limits to their confidentiality.

So unless you refuse insurance completely AND never provide superbills, I suggest you always cover the possibilities of insurance records requests with all of your clients to make sure you’re covered and the clients know the potential outcomes.

And this brings us back to what I mentioned before, that clients should know they’ll have a diagnosis on file. Insurance requires a diagnosis to establish medical necessity for treatment.

The key here is making sure your clients know they will have a mental health diagnosis on file AND it’s important that you consider what that mental health diagnosis is.

It is considered insurance FRAUD— illegal, unethical, something that could lose you your license—to give an inaccurate diagnosis.

What does accurate diagnosis mean?

It means that if a client has a “severe” diagnosis, that you don’t under-diagnose them. For instance, not wanting a client to deal with stigma of bipolar disorder, so diagnosing them with adjustment disorder instead. Read more in this blog about common diagnosis issues.

This also means that if a client doesn’t meet the criteria for diagnosis, insurance companies won’t pay for therapy, and it’s illegal to give them a diagnosis (like Adjustment Disorder) if they don’t fit the criteria. So you should have a note in your paperwork that clients who do not meet a diagnostic criteria likely can’t bill insurance.

If you’re still not sure you understand this, there is plenty more info to educate yourself! Check out my free crash course where we talk about insurance, as well as notes, intake paperwork and treatment planning.

Avoid Fraud When You Diagnose

Here’s a common scenario: A new client comes in, obviously in need of your services. You want them to be able to use insurance because you know how important therapy is and want to make sure they get what they need. So you diagnose them with something —anything— to make it happen. 

You think you’ve done them a favor, but what you’re really doing is committing FRAUD.

It happens every day, and most therapist don’t even realize they’re breaking the law. I’m here to help you avoid fraud! That’s why I want to talk about the major mistakes people make when giving a diagnosis for insurance. 

Watch the video to find out more or keep reading below…

The first thing to remember is that any diagnosis you give, for any reason, must be real and accurate. So get out that DSM and make sure!

Even when I was diagnosing people every day as part of an agency job, I always double-checked the criteria for every diagnosis, every time. Why? Because even when we think we know a diagnosis inside and out, the DSM offers crucial guidance to getting it right. And unless you have a photographic memory, you probably don’t remember every single component of every diagnosis. 

The two big mistakes people make in a diagnosis that often lead to fraud are over-diagnosing and under-diagnosing. 

Let’s look at a common diagnosis to see how this works in practice: Adjustment Disorder.

Under-diagnosing


In under-diagnosing a client, you’re probably forgetting the ‘rule of severity.’ One of the main criteria for adjustment disorder is that if someone meets the criteria for another, ‘more significant’ disorder, you *must* diagnose them with the other disorder.

For instance, you may have a new client who fits the criteria for Bipolar Disorder and sought you out while in the middle of a Major Depressive Episode. If that’s the case, you are not allowed either legally OR ethically to diagnose them with Adjustment Disorder.

Sometimes we therapists worry about documenting something like Bipolar Disorder, concerned the diagnosis might do harm to our client.

In those cases, our job is to remember how important it is for our clients to have accurate medical records for their own health, as well as for us to be doing the best job possible providing the services our clients need. We fail at both of those if we don’t diagnose properly.

Over-Diagnosing


Over-diagnosing looks like this common scenario: a client comes to you in major distress, even though they don’t meet the criteria for any specific disorder. They could be experiencing a major transition or experiencing stress related to job loss, a major move, etc. In cases like this many therapists will ‘fudge’ a diagnosis; after all, everyone meets the criteria for adjustment disorder, right?

Well as much as I like fudge to eat, it’s a bad idea for diagnoses!

You don’t want to give someone a mental health diagnosis if they don’t actually meet the criteria, because you have no idea how it might impact them in the future. It’s just as bad as under-diagnosing to avoid what you might consider a ‘harmful’ diagnosis.  

Basically, therapists should never (ever!) give a diagnosis to a client unless they meet the criteria.

If you want to keep the insurance companies happy, clients happy, and yourself protected, diagnosis is just one part of what you need to consider for clients who use insurance. Click here to check out everything you need to know about insurance and medical necessity. 

More of My Favorite Intake Assessment Questions

You may have already read about My 4 Favorite Assessment Questions but let's get into some more! In this video I'm sharing four more questions I recommend you ask your clients during the intake process.

These questions will help you get the necessary historical data to treat them best but also help you make a connection more easily.

Still have questions about the intake assessment process and questions to ask clients? Then check out this blog post on Assessment Dilemmas and FAQ's to get some tips on how to simplify the intake process. 

Let us know in the comments below what your favorite questions are to build rapport with clients and get the information you need to provide them the best therapy possible. 

What is Medical Necessity?

Medical necessity is a term that is based on the medical model of treatment but is also applied to mental health treatment. Sometimes that can be confusing for those of us who are counselors, therapists, social workers and psychologists!

In this video I explain:

  • The three main components of medical necessity

  • Why insurance companies use medical necessity for mental health

  • Where you want to highlight medical necessity in your documentation

Let us know what you think in the comments below:

Are there other strategies you use to talk with insurance companies about medical necessity and psychotherapy?

Does this seem to cover what is needed for your progress notes and insurance?

Step-by-Step Intake Progress Note

Did you know that your very first progress note should look different from your other client case notes? 

That's because the first session with clients, the intake assessment, is very different from our "typical" sessions... whatever "typical" looks like to you ;) 

In that first session with mental health clients we have forms to review and information to gather. And there are very important things to discuss with our clients so they understand the counseling process.

I recommend including that you reviewed all of these things in every intake progress note you complete (obviously, with the understand that you actually did review those things with the client in session):

  • Limits to confidentiality

  • Potential benefits and drawbacks to treatment

  • Consent for treatment

  • Attendance policy

  • Communication outside of session

  • Reason for seeking treatment

  • Assessment of symptoms

  • Assessment of biopsychosocial data

  • Plan for treatment

Some sections may have more or less detail, depending on the client's situation or length of the session.

For example, it often takes more time to do an intake for child and adolescent clients because we want to get information from the caretakers, as well as the client. Others simply do a more in-depth assessment and take 2-4 sessions. 

When that happens, simply document the portions you did cover (and with whom you discussed it) and then what you plan to cover in the next session. However, I do recommend that you review limits to confidentiality and obtain consent at the first session, whenever possible.

Want to see an example progress note?

I've got one for you! Check out this sample intake progress note below to see how it looks when we put it all together. I'm using the DAP note format here...

Data: 

Client arrived early and had completed intake paperwork online using client portal. Reviewed with client the limits to confidentiality, potential benefits and drawbacks of treatment, communication outside of session and attendance policies. Obtained consent for treatment. Discussed biopsychosocial history further and completed all intake paperwork. Assessed reason for treatment, current struggles and symptoms. Identified goals for treatment. Current goals include 1) Creating a routine for relaxation and self-care and 2) Identifying priorities and planning for work and home tasks accordingly. Client requested weekly assignments to stay on task so we will use this format to start and evaluate after 6-8 weeks. 

Assessment:

Client was comfortable disclosing details about prior treatment and mental health history. Exhibits excellent insight and desire for continued personal growth but is frustrated with ongoing struggles and feels she is not meeting her potential. Previously treated for both depression and anxiety, for which she has created excellent coping strategies and continues to use cognitive-behavioral techniques to address. Currently struggling with symptoms related to ADHD as primary concern.

Plan: 

Client will attend weekly sessions in the office, with the option to move to online sessions if needed. Therapist will assist client in identifying the appropriate weekly “homework” tasks before the end of each session. Client will provide one check-in via journaling in client portal once per week outside of sessions. Weekly assignment is to gather all to do lists and pending tasks to bring in for next session and label with priority level. Next session scheduled for 05/19/17 at 12pm.

You're probably thinking, "Does my intake progress note need to be that detailed?"

Maybe not... that all depends on the situation, as well as how in-depth your intake assessment is. For example, if you don't use homework or if you didn't have time to review treatment goals, this note would be a lot shorter.

On the flip side, if you had to do an assessment of safety because the client reported feeling suicidal, your note might actually be longer

Notice that this note doesn't include anything I would have in my intake assessment form.

That's because I see no reason to write the same thing multiple times!

This used to drive me crazy when I worked in an agency. And it's a reason that soooo many therapists resent paperwork and fall behind. That's why I recommend you streamline your documentation (and especially, your intake assessment process) as much as possible. 

If you have questions about substance abuse, past treatment, relationships, and suicidal ideation in your assessment form, then why do you need to write these things over again in your intake progress note? My opinion is that you don't need to duplicate this... but you do need to have it documented somewhere that makes sense.

So, if you miss something on your intake assessment form, then write it in your intake progress note and vice versa. 

I've got a notes checklist you can download to create your own intake note template or to use as a reminder when writing your intake progress notes.

Enter your info below to sign up for my weekly emails and then check your inbox to download the checklist! Remember to check your spam or junk folder.

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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...

My 4 Favorite Assessment Questions

Favorite Assessment Questions Therapy

I've mentioned before that clinical assessment is one of my absolute favorite topics, and one of my favorite things about being a therapist. 

I was fortunate that early in my career I was required to complete LOTS of intake assessments and this forced me to become good at two things in particular- time management and asking good questions (not to mention typing and writing quickly, too!). 

So I thought that I'd share with you my favorite assessment questions that I've continued to find useful over time. Many times, asking these questions leads into powerful and detailed conversations about the concerns clients are bringing to therapy

I encourage you to try them out and adjust as much as you like to make them fit with your clientele in each situation.

1) Describe a typical day for you.

I know, I know. The first one isn't even a question! But it's one of the first things I review with clients when they come in and I find it often leads in to getting more details on the way in which their identified problem impacts their every day life. Going through their typical day prompts them to think of things they may not have considered if I simply had them list off general concerns.

By the way, I do actually have them list off general concerns ahead of time in a quick checklist (available in my Paperwork Packet). But this question often leads in to much deeper topics.

Quick Tip: Adjust this for interviewing parents about child clients.

Parents often have difficulty identifying how often behaviors occur in children. It is important to get a detailed picture of this so you can highlight progress along the way, for the sake of both the parent and the child. 

When parents describe problem behaviors, ask how often they occur by going through their day. How often does the behavior occur between waking up and going to school? How often while at school? How often between returning home and having dinner? How often between dinner and going to bed?

This will help you identify times of day that may be more problematic, triggers to behaviors, and also give you a detailed baseline to visit when you want to praise the progress that is being made in counseling.

2) What strategies have you already used to try and solve the problem?

This question is very important to me because it helps us identify what doesn't work, or how to adjust the strategies already used. Most people have already tried solutions on their own or may have reached out to other professionals for help, whether that's another therapist or a religious leader, an acupuncturist, or a psychic.

Dig in to what led them to seeking out those solutions and why they didn't work. Some may have worked up until a certain point or helped with one aspect but could not address the whole problem.

This will often bring up the deeper meaning behind a more superficial problem or identify other areas that impact the problem for which they are coming to therapy. Then you're able to identify how you can best work together, what the focus is, and where is the best place to start.

Lastly, this also a great way to discover your client's resources, network of support, and personal strengths. These are all things you can use within therapy to assist process and progress. 

3) What would you like to get out of counseling? How will you know you are ready to finish?

Somewhat related to #2, I find this question hugely valuable. This is what helps guide me throughout my work with the client because I need to stay on task.

Of course, things may change and new things will come up over time, but knowing the client's goal helps to steer the ship and know whether something should be passed up (perhaps to address later on), addressed head on, and if you may need to take land at one particular problem for an extended period of time.

This is also a way to help clients who are having difficulty transitioning out of therapy. You can point them to their own goals and reasons they would know they are ready to move on. That's why I do document this one specifically, both by asking the client to write this out before seeing me and in my notes for that session in which we discussed it. 

4) Have you ever been arrested?

A little less "touchy-feely" than the above questions, but this question is still one of my absolute favorites that also provides a wealth of information. 

Note that this is different from asking whether or not someone has a criminal record.

This is a really key distinction. The point of asking about arrests is to gather information about potential problem behaviors that may not have resulted in a criminal charge. This also helps to simplify the question because, in my experience, many people do not view misdemeanors or DUI's as a criminal record and will genuinely answer "No." 

This question will be more or less important based on the type of work you do, but it is still an important question to ask every client in every setting. 

Never assume that someone does or does NOT have a criminal record or arrest history based on their presentation! I have had many unassuming people whom I would never predict having a record answer "yes" to this and it has been important for our work together.

For child and adolescent clients, it is important to follow up by asking "Has anyone in the family ever been arrested?" 

Obviously, this can provide information that you would often not receive by simply asking about a criminal record. And, regardless of guilt or charges being made, arrests of loved ones can significantly impact a child's emotions and view of the world. These are important things about which to be aware. 

There are so many things we could potentially review with clients during our intake assessment. 

This is obviously not an exhaustive or required list. But I have found all of these to be very helpful in a variety of work situations, including private practice. Some of them are in my intake assessment that I have clients complete ahead of time, and all of them I definitely review in person. 

What other questions have you found helpful during the assessment phase in private practice, or other settings? Share in the comments below!

Drafting Your Personalized Note Template

One way I recommend counselors save time on notes is to choose a notes template and stick with it. In my Private Practice Paperwork Crash Course I review five different types of templates you can use and these are basic copy and paste topics you can use across the board.

However, I do get feedback occasionally that some therapists have adjusted the templates and when they do this, therapists tell me the template is much easier to use and much more meaningful to their work... because it's personalized.

So, I thought I'd review all the different components of common therapy notes templates in case you'd prefer to simply pick and choose what works for you. These components all come from the following note template formats: DAP, GIRP, PAIP and SOAP.

I encourage you to check out what sections appeal to you and seem meaningful to your practice. Choose those and create your own therapy notes template that you'll find easy to use every day.

These are simply listed in alphabetical order, with no identified level of importance.

Assessment

This section focuses on the clinical assessment of the client's symptoms, progress, presentation, etc. Here you can add more clinical language and also outline how the session may interact with previous sessions or experiences, as well as highlight things you think may be important to monitor.

Data

This is the same as the "Objective" section below (so just choose one). Here you will add information that is objective and behavioral. These are things that occurred in session and any lay person would be able to describe. This could include quotes, acting out, crying, refusing to participate, nervous movements, etc. If it could be heard or seen on a video camera by a person on the street, then it goes here.

Goal

This is typically at the top of the note and includes whatever goal(s) the client is working on. Rather than making things complicated, simply copy and paste from your treatment plan wording. Keep it simple and direct, but also monitor to make sure your sessions are really in alignment with the goals you are including with each note.

Intervention

These are the actions of you, the counselor leading the session. Whether this is something you did passively (like building rapport) or more actively (like teaching a technique), this section is meant to capture where you directed things and how you responded. If you tend to review or teach techniques, direct clients in certain behaviors or challenge and examine thought patterns, this will be an important section for you to include in your notes.

Objective

This is the same as the "Data" section above (so just choose one). Here you will add information that is objective and behavioral. These are things that occurred in session and any lay person would be able to describe. This could include quotes, acting out, crying, refusing to participate, nervous movements, etc. If it could be heard or seen on a video camera by a person on the street, then it goes in this section. 

Plan

The plan is one of the most important components of any notes template and I recommend you have a Plan section regardless of what other sections you include. This is where you identify follow-up, whether that is for you or the client. Here you can clearly identify how the client may incorporate what was learned in session over the next week. And you will also include when is the next planned session. This is crucial for documenting your continuity of care.

Problem

Similar to the "Goal" section, the Problem is whatever problem area the client identified they would like to work on in therapy. This may be just as specific as a goal, or may be somewhat vague, such as depressed mood or anxiety. Regardless of the specificity, this will help guide your treatment and allow you and the client to know you are on the same page with where things are headed.

Response

This section is the opposite of the "Intervention" section because it is focused solely on the client and how they reacted to things during session. Similar to the "Data" section you will want to include objective information that would be easily seen or heard by anyone in the room. However, if you choose not to have an "Assessment" section, you may also include more subjective responses made by your client as well. Also, remember that refusing to participate or react to something is also a type of response and should be included here. 

Subjective

This section is opposite to the "Objective" and includes information shared or observed during the session that is either subjective to you or to the client. This could include things like a prognosis or an interpretation of a response. It could also include subjective statements made by the client themselves.

So, how does this all look if we put it together in new formats? You'll notice that some sections are similar and I never recommend duplicating your work, so choose what you like best to have a complete note.

Some examples could be: 

PDAP (Problem, Data, Assessment, Plan)

GOAP (Goal, Objective, Assessment, Plan)

PIRP (Problem, Intervention, Response, Plan)

PIRAP (Problem, Intervention, Response, Assessment, Plan)

SOIAP (Subjective, Objective, Intervention, Assessment, Plan)

The amazing thing about being a therapist in private practice is that you get to make these decisions! Don't let it overwhelm you, let it make you a better clinician by personalizing things to yourself and your clients as much as possible. 

One last recommendation is to consider using one format for ongoing notes but a different template for assessment. A participant in my Meaningful Documentation program did this and found it was much easier for her to write the more in-depth assessment note for the first session but then she could take things down a notch going forward. 

Play around with things and see what works for you. Don't make it too complicated but also understand that sometimes creating these systems does take time. However, once you have a clear format for writing progress notes you are able to do them much more quickly and with less mental effort. 

That way you can spend time on what is most important- the clinical work!

Leave a comment below and let me know what you decided if you choose to mix and match. I'd love to hear and so would many of your colleagues!

Prepare Your Records for Release

Releasing records is an intimidating issue for many counselors and therapists. And while we hear a lot of rhetoric on the topic, many counselors are not clear on legal and ethical expectations and end up making poor judgment calls because of that.

A common scenario is that a client requests their records and a counselor automatically refuses to release the records, stating confidentiality concerns. While these concerns are valid, that is not following the law within the United States. Clients do have the right to access their records. From their physician. From their physical therapist. From their mental health therapist.

There are some exceptions and those differ slightly among state law; however,  those exceptions are typically in more extreme cases and require the therapist to prove that access to the records would cause significant harm. Furthermore, these laws still often allow access of the records to someone the client designates.

Does this mean that therapists then release records automatically any time a client makes such a request? Not necessarily. 

The most common practice is first to talk with your client about the purpose for the release. Determine what it is they are hoping to gain from releasing or accessing their records. Oftentimes, this discussion will help the client identify that they actually would prefer a treatment summary from the counselor.

During this discussion with your client it is important to highlight anything that could potentially be misconstrued or misinterpreted if released. However, there are many times when the client still requests the records and the therapist is required to release them. This can be an unsettling discussion for many therapists and that's why I encourage you to consider these scenarios ahead of time, before any complicated situation arises.

I have some strategies you can use to make releasing your records (if necessary) a much less stressful experience:

Think about your client viewing their notes

When writing notes, treatment plans and assessments, work under the assumption that your client will one day view these. This practice helps you to keep language more objective, strengths-based and to the point. 

This does not mean you hide important details or only write the positive things about your client. Keep things honest and real. Your ethics require you to document what actually happened as well as your professional assessment of the client's situation. However, there are often minor tweaks that therapists will make when considering their client actually reading the note and this will improve the objectivity and clarity of your notes.

Think about and discuss your policies

It is important to make sure your policies for releasing records are outlined in your informed consent document... and that you review this with your clients at the outset.

I do not recommend saying in your policy that you will NOT release records because this is not a practice you can legally uphold, except in special circumstances. Instead, note that you will discuss with your client the reasons for the request and make recommendations accordingly. This encourages collaboration should your client make a request at some time later on. 

Also, you can choose to charge for things like making copies, time spent writing a treatment summary or time consulting with other professionals on behalf of the client (such as their attorney). However, if you don't have these charges outlined in your Services Agreement then you may end up spending money and time without reasonable reimbursement. 

In my paperwork packet available for purchase, I make sure to include these things, along with a more in-depth court policy provided by Nicol Stolar-Peterson, LCSW BCD from www.therapistcourtprep.com. If you already have a paperwork packet but are looking for a court policy to add on, you can purchase that on her website for a very reasonable $37. 

Have the insurance conversation

Lastly, if you have clients who are being reimbursed by their insurance company or if you contract with their insurance company, make sure they are aware that all records can be accessed by the insurance company. Like it or not, by allowing a third party to pay for services, clients are also allowing a third party to check up on those services

That also means that you need to consider how that relates to your records. For example, many therapists will downplay client symptoms in an attempt to avoid stigmatizing their clients. However, to an insurance company that makes it seem as though your client doesn't need the services you're providing. FYI, it's also considered fraud to either "downgrade" or "upgrade" your client's diagnosis. 

That's why a basic, easy to remember rule with documentation is to always keep things honest. 

However, if you're looking for help specifically with how insurance and your paperwork connect, you can check out my new on-demand training The Counselor's Guide to Documenting for Insurance (now available as part of the Meaningful Documentation Academy). There are so many things to think about with your work, let's make paperwork as stress-free as possible!

Do you have any other tips on what to consider when preparing your records for release? Any tips from past experience? Feel free to share in the comments below!

Writing Therapy Notes for Insurance

Maybe you've looked through some of my resources and have wondered "but does this apply to insurance?" Well, this post is for you!

While notes don't generally need to be that different when taking an insurance company into consideration, there are certain things you want to make sure you have covered. And, if you contract with Medicare or Medicaid (Medi-Cal here in California), you need to follow these tips to the tee! Yup, those two are a little more on the stringent side when it comes to documentation.

Let's take a look at what an auditor is looking for when reading your notes! Oh, and did I mention I used to do that for a living? So yes, I know a thing or two about what insurance is looking for in therapy notes ;)

  1. Have you addressed each condition listed? This means if you identified more than one diagnosis or problem, you need to make sure you're addressing them both in some way. That could mean collaborating with another provider (especially with things like substance use) or simply having two different treatment goals to cover each area. The key with paperwork and insurance is always that you can't leave the reviewer with a cliff hanger. So, if you mentioned that your client has both anxiety and depression, outline how you're addressing both these issues. Don't leave them wondering or looking for more.

  2. Did you accurately separate out what may be different problems? There are many reasons for behavior and we all know that diagnoses can present very differently in different people... and many diagnoses have overlapping symptoms. Insurance companies expect you do a thorough enough assessment early on so you can differentiate among these things. For example, is your client having trouble sleeping, trouble concentrating and isolating from their spouse because they are depressed or because they have a substance use disorder? You need to be able to identify a clear why for what you're doing with this client, and that includes an understanding of what is leading to their reason for seeking treatment.

  3. Did you justify your diagnosis? Every insurance plan requires a diagnosis for reimbursement. This is where many therapists end up causing harm for their clients... and getting themselves in some ethical (if not, legal) trouble. It is your job to provide an accurate diagnosis based on your clinical assessment. What does this mean? NO UNDER OR OVER DIAGNOSING! If your client truly has an Adjustment Disorder, go ahead and list that. But if they actually have more significant symptoms that meet criteria for a Major Depressive Episode, it is fraudulent to give them a "lesser" diagnosis. Likewise, if your client has some difficulty and comes to see you for self-improvement but doesn't actually meet the criteria for any diagnosis, you should not inflate their symptoms to meet the criteria just so they can be reimbursed by their insurance company. And let me tell you from experience, it is pretty easy to notice when a clinician is over or under diagnosing... so just keep things clean and diagnose based on what you see.

  4. Do you have a plan for how to address this client's problem? It's not enough to identify a need and then start therapy. A reviewer wants to know that you have a plan for how to treat this specific problem. You don't need to write a huge treatment plan or outline every possible intervention you'll provide but you do need to outline how you see therapy progressing. If you can do that with an estimated timeline, even better! And if writing a treatment plan seems overwhelming to you, I offer a free treatment plan template in my Private Practice Paperwork Crash Course.

  5. Is your plan something the insurance company should pay for? Any time you have a third party paying for a service, they want to have a say (click here to learn more about what that means for you as a counselor contracting with insurance). And specifically, insurance is looking to make sure that you are providing a needed and professional service that is appropriate to this client. Let's break that down some more...

    1. You're providing a therapeutic service that requires a Master's Degree or higher. I like to call this the "Grandma rule." Basically, no insurance company wants to pay you to do something someone's grandmother could do for them. Think things like "active listening," "building rapport," and "providing empathic support." These are all wonderful things and are fine to include in your notes. However, when they become the only thing in your notes, a reviewer starts to question your services, because these are things almost anyone without a Master's degree can do. My grandmother is wonderful and when I talk with her she actively listens, shows empathy, and holds space... and she's not providing me counseling. She's talking with me as a close relative. So, show the insurance company you can do all those things plus the awesome stuff you paid all that money to your grad school to learn.

    2. Even if you're doing a fabulous job outlining your clinical work, make sure not to overlook the fact that this service also needs to match your client's needs. If they have a substance use problem, are you trained to address that? Are you providing a reason for using EMDR? Unfortunately, there are therapists out there who will see any and every client who calls simply because they are desperate for money. Insurance companies know this and don't want you to waste the client's time treating them when you're not well-equipped.

  6. Have you identified how the client is progressing or why they aren't progressing? Each week, you'll want to evaluate the progress your client is making in their treatment plan. This doesn't need to be time-consuming and doesn't even mean you need to look at the treatment plan each week. However, it does mean you can't abandon the treatment plan. I often see that therapists write wonderful weekly notes, none of which identify whether or not the client is actually making progress on the goal they identified and none of which make a lot of sense when put together week by week. Check in with your treatment periodically to make sure your notes flow with it. Mention progress in notes, even if it's a lack of progress... that still shows you're following the plan and adjusting as needed.

  7. Do you have a specific maintenance plan? For clients who are improving but still need some assistance, insurance wants to see that you have a clear plan for maintaining the progress made and weaning the client off treatment. I know, I know... this is what many therapists dislike about insurance, the fact that it dictates the end of therapy. However, if you can provide a reasonable expectation for the end of treatment and clearly outline why each step is needed, your client is more likely to be able to continue with you.

  8. Overall, are you following the insurance company's definition of medical necessity? In a nutshell, insurance wants to see that you have clearly shown the client meets medical necessity and are following their protocols related to that.

Sure, there's more to writing therapy notes for insurance companies but that definitely covers a lot of the big areas. If you want more help with writing notes or with documentation in general, check out my Meaningful Documentation Academy.

Let me know in the comments if you have any other tips or what was your biggest takeaway!

  

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. 

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.

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 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!