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Insurance Audits: How to be Prepared!

Posted By Jim Broyles, PhD, OPA Director of Professional Affairs, Wednesday, April 12, 2017

I have spent considerable time in the last couple of years providing OPA members help and support with insurance issues. Often, concerns from psychologists arise when an insurance company questions individual psychologist’s billing or record keeping practices. When these questions are raised, psychologists often feel confused about whether, what kind, or how much information an insurance company may need, what they are entitled to, and how to provide this. This past month has been no exception to this ongoing need for clarification. Many who follow the listserv or read my emails know that Medical Mutual recently contacted several Ohio psychologists through an auditing company, Change HealthCare, to raise questions regarding billing codes used by psychologists. My experience with these issues continually leads me back to some basic suggestions for most of us who provide clinical services: a little bit of preparatory work can go a long way toward being ready for audits or other kinds of scrutiny from insurance companies. With this in mind, I would like to make the following suggestions:

  1. Make sure the initial consent document used in your practice includes language designed to provide consent for releasing patient information in response to a broad array of insurance company requests.

    For example:
    You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record.... By signing this Agreement, you agree that I can provide requested information to your carrier.

    This allows for the release of basic clinical information which may be required by the insurance company.

  2. HIPAA allows for psychotherapy notes to be kept separate from the rest of a client’s clinical record, and offers a greater level of protection for these notes.  I suggest psychologists maintain this separate record. This allows for less sensitive, more basic clinical information to be easily released in response to an insurance company audit while offering greater protection for client privacy.

  3. Most insurance companies require that we follow basic record keeping guidelines set primarily by Medicare. When billing time based CPT codes, the more general clinical record should include documentation which supports the procedure (separate from the psychotherapy note) for each session billed including:
  • Session start and stop time
  • Modality
  • Diagnosis
  • Symptoms
  • Functional Status
  • Focused Mental Status Exam
  • Treatment plan goal addressed, prognosis, and progress
  • Name, signature, and credentials of the person performing the service

Following these suggestions will help many psychologists to readily respond to most audits conducted by insurance companies for the variety of reasons that I am familiar. More detailed guidelines on record keeping will be provided during my workshop at OPA’s upcoming convention (Thursday, April 27 at 9:00 a.m.). I hope to see you there! 

Jim Broyles, PhD
OPA Director of Professional Affairs

Tags:  insurance  Insurance audits 

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