Among the many insurance issues OPA members contact me about, the most distressing for most is experiencing an audit or threat of audit from an insurance company. The vast majority of OPA members bill many of their services to insurance companies. However, documentation and record keeping requirements are not always clearly understood by these same clinicians. In their effort to clear the confusion, many psychologists attempt to learn about what is required of them. Unfortunately, this effort can lead to more confusion as they learn there are multiple sources for these requirements. Requirements and guidelines emerge from federal law, state law, ethical principles of the American Psychological Association, and other sources. These requirements consider the array of services which can be offered by a psychologist and attempt to identify what information should be kept as part of the record, at what level of detail, for how long, as well as many other standards.
In an effort to shed light on this very confusing issue, OPA’s Insurance Committee has created an Audit Toolkit. This tool kit is free to all members (and may be purchased by non-members) and offers a checklist of clinical record details considered critical by most insurance companies. While individual companies may vary somewhat in terms of their requirements, most follow an industry standard which is set by the Centers for Medicare and Medicaid Services. These standards require that testing and psychotherapy services must be medically necessary if they are to be reimbursed by health insurance companies, and that the record of these services must include certain details to document this medical necessity. The record itself must establish a consistent connection between symptoms present, diagnosis, treatment plan goals, and tasks of psychotherapy sessions. (This connection is sometimes referred to as the “Golden Thread.”) During audits, insurance companies often look for documentation of these details to establish medical necessity, and have been known to reclaim funds paid for services when this necessity is not established to their satisfaction.
OPA’s Insurance Committee has taken all these factors into consideration in creating their toolkit checklist. It is quite likely that its use when creating clinical records will help any clinician face an insurance company audit with confidence. OPA members may click here to access their FREE toolkit. My hope is that members will find this member benefit useful. As always, please feel free to reach out to me with question and suggestions.
Jim Broyles, PhD
Director of Professional Affairs, Ohio Psychological Association