Top 5 Insurance Compliance Tips: A Provider’s Guide

Meeting insurance documentation standards and requirements can be easy once you implement best practices and methods within your workflows. Alma has thorough experience in helping clinicians consistently reach these requirements and we’ve partnered with clinicians like Barbara Griswold, LMFT to make this process as stress-free as possible for clinicians.

From drafting progress notes to managing insurance audits and denials, we're able to help clinicians overcome any obstacles in regards to insurance compliance.

1. Treat progress notes as a form of protection

Despite their reputation, the reality is progress notes do serve to protect you and your private practice in a multitude of ways. Maintaining clinical documentation that meets compliance standards set by payers helps ensure you’re paid appropriately for all your time and effort. Failing to maintain compliant documentation that meets payer standards puts you at risk of being audited and/or experiencing claim denials.

For clarification - compliant documentation includes initial intake notes, treatment plans, progress notes, and the codes you use to submit claims. This documentation has always been required by mental health licensing laws and insurance companies that providers are credentialed with. Payers want “medical necessity” to be demonstrated in these forms of documentation to prevent fraud and waste, which is really why providers must focus on this area.

What does “medical necessity” mean?

Insurance companies require that care provided to a client is necessary, appropriate, and based on their diagnosis, symptom acuity, and level of functioning. The care a client receives must also be based on evidence-based approaches to treatment.

Medical necessity should be addressed in the body of your treatment plans and progress notes, as payers use medical necessity as a benchmark to determine whether to reimburse a claim.

2. Complete your progress notes right after the session

A common mistake clinicians make is putting off writing progress notes until later in the day or week, which can make it difficult to recall crucial details that should be included within the notes.

This can lead to professional conflicts as progress notes provide critical information to insurance companies and heavily influences their decision to approve, extend, or discontinue a treatment plan. Well-made progress notes also serve as an easily-referenced record of treatment, which can prevent lawsuits and help provide better care to clients

In addition, treatment record entries should also be made on the date you provided the services and should include the date of service.

Remember that insurance companies have the right to request these notes at any time, so it’s important that this information is as accurate as possible.

Progress note best practices

Other best practices as they’re related to progress notes include:

• Avoid using abbreviations
• If writing by hand, ensure that notes are legible and always easy to read
• Notes should always be signed, and include your degree, license, and credentials.
• If your notes are electronic, finish with your name or “signed by John Do, LMSW”
• Do your best to include accurate start and end times as closely as possible (e.g., 1:03–1:58pm)
• Include the date for the next appointment, whilst explaining any unusual delays in the schedule

Alma members have access to these Compliant Insurance Documentation FAQs that further detail requirements and other best practices for progress notes.

3. Don’t fret over an insurance audit

When it comes to insurance audits, it’s best to adopt the mindset of “when it’ll happen” vs “if it’ll happen.” That’s because insurance companies have the right to request records or a summary of notes whenever they cover a part of a client’s session.

Though, audits and records requests can still happen even when you’ve never signed an insurance plan contract. As soon as an OOP (out-of-pocket) client submits an invoice/superbill to a plan for reimbursement, that opens up their treatment and notes to be reviewed by their health plan.

The health plan can contact you by phone to review whether or not they want to pay for the claim that was submitted for your services. They can also ask for your notes, which is rare, but still possible. And if your notes don’t meet their standard, your clients risk not receiving their reimbursement. But keep in mind that audits aren’t the only reason why a health plan may contact you.

The top three reasons an insurance payer may reach out are:

1. Treatment reviews: A treatment review is when a representative from the health plan reaches out with the goal of reviewing your care to conclude whether they want to pay for future care and at what frequency. They’re checking to see if the treatment is necessary and if the frequency of sessions is appropriate for the client’s specific diagnosis. This typically happens over the phone and they rarely ask for your records or notes.
2. Administrative audits: Administrative audits are required by federal agencies or by the plan’s oversight agencies. It’s important to note that these audits are not claims related and come in two forms. The first type is a treatment record audit, where they want to see whether you have everything in your chart that you’re supposed to have. The second is a risk adjustment audit, which is the most frequent type you can expect to receive.
3. Claims audits: Claims audits are the only audits that are related to payment, and tend to be what clinicians have in mind when they think of a traditional audit. They also come in two forms: pre-payment audits and post-payment audits. Pre-payment audits are when the health plan pauses a claim until you can provide notes for these sessions. And post-payment (or “retrospective”) audits occur when a health plan goes back through claims they’ve already paid, and reviews your notes to make a determination of whether they should have paid or if your notes are good enough.

4. Review Alma’s compliance FAQs

With all that’s included within the world of compliance, it can be difficult trying to stay updated on what’s going on within every corner. These answers to common compliance related questions can add some helpful transparency to your professional life.

What tools and resources does Alma offer to help providers meet compliance requirements?

Alma offers educational articles, webinars, and live office hours to help our providers create and maintain compliant clinical documentation.

Note: These resources are only accessible and available to Alma members

Documentation Office Hours

• Licensed psychologist, Alma member, and Alma's VP of Clinical, Elisabeth Morray, hosts bi-weekly office hours for our members to discuss best practices in completing compliant documentation and navigating insurance audits.

Support Center Articles

• Compliant Insurance Documentation FAQs (includes a detailed “progress notes checklist” to help guide your notes)
• Clinical Documentation in the Alma Portal: Notes and Treatment Plans
• Note Taking in the Portal: Progress Notes
• Common Requirements of a Treatment Plan
• Responding to Medical Records Requests
• What to Expect with an Insurance Audit

Ebooks and Guides

• Medical Coding and Billing Guidelines
• Telehealth Best Practices

Recorded Webinars

• Writing Efficient and Effective Progress Notes with Barbara Griswold
• Avoiding and Dealing with Insurance Denials with Barbara Griswold
• Audits, Record Requests and How to Avoid them with Barbara Griswold

What does it mean if my documentation is audited?

Audits are not unusual. They can happen for a number of reasons and may be a result of the following:

• Atypical billing patterns, including sessions coded in a way that does not align with CPT, ICD-10, or payer guidelines or instances where the CPT or diagnosis codes chosen don’t represent the services performed or session notes.
• Lack of notes produced for a session upon request, or lack of response to a notes request within five business days.

Alma members can visit “What to Expect with an Insurance Audit” to learn more.

Does Alma have access to provider documentation?

The contents of notes are not accessible to Alma employees without your permission. In the event that we need to provide notes to an insurance company in response to an audit, we will first reach out to you for permission to securely download notes, prioritizing your patient’s privacy. Read more about HIPAA compliance at Alma.

5. Adopt an easy-to-use system for clinical documentation

Having all your important clinical information stored in an efficient documentation system makes your job much easier when working to ensure compliance. Alma serves as an effective documentation system by allowing providers to manage all their necessary clinical documentation in the same place, which eliminates the need for any costly third-party platforms.

Alma also supports providers in navigating any possible audits and can offer helpful resources and education.

Keeping your clients’ data safe is also made easier with Alma’s ability to store records within a HIPAA-compliant member portal.

Learn more about the benefits of using Alma by clicking the button below.