I’ve written a lot about audits and records requests, but not much about treatment reviews, something we should all know about and be ready for.

There’s a moment of dread when you get “THE CALL.” It’s an insurance plan, asking for a treatment review.

If you are an out-of-network therapist, you may be especially surprised to get this call.  You may not realize that as soon as your client submits a superbill or claim to an insurance plan, it opens the door for your treatment to be reviewed.

So, before I answer questions, I want to urge you to breathe.

 It’s understandable to feel anxious before a clinical review, because your client’s therapy coverage is on the line. But you are the one who knows the case, who knows the client, and why they need and deserve treatment.  With a little practice you CAN learn to speak the language of medical necessity (more on that below) so that you can defend your client’s care.  If you understand what’s required, commit to preparation, and speak the language, you can ace an insurance treatment review.

Here are some answers to common questions about treatment reviews.

“What is a treatment review?”A treatment review (also sometimes called a clinical review) is when a health plan contacts you to ask questions about your treatment.  It is not an attempt to ask for their money back for past sessions, and rarely involves a request for records.  The plan is checking to see if they feel future treatment is necessary, and at what frequency.  It will usually be a phone conversation.

“Is it a kind of audit?”  Not really.  In a record request or audit, the plan reviews charts to confirm that you’re keeping the kind of documentation that they require to support your billing.

“What can trigger a treatment review?”   A common trigger is seeing a client multiple times per week.  This might be required if a client is in crisis, but if you maintain that frequency for months you may get a call from the plan to review whether they feel it is necessary.  Another trigger might be performing more sessions than average given the client’s diagnosis. This means an Adjustment Disorder might get reviewed sooner than a Major Depression, as the latter might be expected to take longer to treat.  However, some plans have reviews automatically triggered by session frequency, such as when there have been 20 sessions in 6 months.  You may be chosen for consistent usage of longer session billing code 90837.  Or, you may be chosen at random.

“How can I prepare for my review?”   You may be tempted to “wing it” without preparation, but this can be a big mistake, with serious consequences to you or your client.  Instead, I strongly recommend that you carefully prepare.  You are less likely to be as nervous, and more likely to be successful.

• Call the health plan back, and schedule the phone review, giving yourself enough time to prepare.  Ask for a list of questions you’ll be asked, and the Medical Necessity Criteria they will use to judge the need for ongoing treatment.
• Get my List of Sample Questions for a Clinical Review from my online store to help you prepare.  You will also get a list of questions to use to Interview your client before the Review.
• It is also a good idea to give clients a quick assessment test to have an objective measurement of client symptoms and severity
• Ideally, before the review, coordinate care with the client’s physician or other treating therapists, as the reviewer may ask if you have done this.

“What is the reviewer looking for?”  The reviewer will be listening primarily for one thing: Is the treatment “medically necessary”?  Medical Necessity Criteria involves looking for a few main things:

• whether there are medical symptoms present that back up your diagnosis.  Your DSM diagnosis usually needs to be more than just a Z-code.  Since treatment is not covered if it is solely for personal growth, you’ll need to emphasize that the treatment is necessary, not just desired
• They will also be trying to determine if the level of treatment is the best and most cost-effective and  that the frequency of sessions you are having is necessary.
• Finally, they will be wanting to hear that the client is making overall improvement.
•  Remember: They are likely to be more interested in the facts of the clients symptoms, your interventions, and progress made than in your theories about the case or the client’s attachment style.

“Will they ask about my treatment plan?”  You bet. They will want you to be able to verbalize a coherent treatment plan.   Even though treatment plans are mandated by some states, professional ethics codes, and insurance plans, some therapists don’t write formal treatment plans, and most of us weren’t trained in how to create them.  But a treatment plan is a crucial part of your treatment review.  It spells out your treatment goals, and how you plan to help this client as treatment progresses.  A treatment plan is so important that your treatment approval may hinge on it.

Having a solid treatment plan can help you ace your review.  Check out my pre-recorded webinar “How to Write a 10-Minute Treatment Plan” to learn how to write a brief care plan that will satisfy insurance and all oversight agencies.  For more info, click here.

“What are some common errors therapists make in treatment reviews?”  Common reasons clinicians don’t get approved for more sessions after a treatment review are:

• The clinician wasn’t able to articulate their treatment plan
• The clinician failed to show the medical necessity for treatment in their treatment plan
• The treatment plan was too vague when explaining how progress would be measured
• The treatment plan didn’t include clearly articulated planned interventions
• The treatment plan didn’t address the diagnosis or symptoms