Out-of-Network Records Requests: No One Is Immune 

By Barbara Griswold, LMFT (August 19, 2024)

 

If my email inbox is any measure, it seems the latest trend is an increase in records requests from health plans asking for session notes. What is most surprising? They are asking for the records of out-of-network (OON) therapists.

That’s right, you folks who never signed an insurance contract may have thought you had escaped the mighty insurance overlords.  But you (or your client) may soon be contacted by a health plan asking for your session notes. They may require your notes before they agree to pay the superbill your client has submitted for reimbursement.

The most recent wave of these OON record requests comes from good old OPTUM / United HealthCare.  This health plan just might win my gold medal for “Most Frequent and Nasty Provider Audits” (though it would be a photo finish with Medicare).

Do they really have the right to ask for your notes if you are not a network provider? Sure. As soon as your client submits a superbill and asks the health plan to pay for sessions, it opens the door for plan to review your care — and your notes.

Why were you selected? Bad luck? Well, sometimes yes, it is just random. But sometimes they pick on providers who are doing twice a week sessions for an extended time period, especially if you still have an Adjustment Disorder diagnosis. Plus OPTUM/United does not hide the fact that they may choose to audit therapists who consistently use the 90837 CPT code.

What should you do if you get one of these requests?

• Ask the client whether they want the records released.  The records are theirs, and it is their right to decide whether to release them or to block the release.
  • If they choose NOT to authorize the release of their records, be sure they understand that this likely will mean that the plan will NOT reimburse them for the sessions. The client will have a period of time to turn over the notes, and the claim will be closed if these are not provided.
  • If the client DOES authorize you to hand over your session notes, have the client sign a written release.  You’ll need it before you send anything or even speak to the health plan if you have a question.  

• • • But what should your release say?  It should allow the release and exchange between therapist and health plan for “any information necessary to process claims or superbills, including but not limited to the release of session notes, diagnoses, test results, and treatment plans.” 
    • Since you are getting a release for notes, I suggest you add a phrase that covers the possibility of a telephone treatment review with the plan. Something like “I also authorize my therapist to release information to the health plan for a telephonic treatment review, if requested by the plan.” 

If you haven’t received a records request yet, this can be a great wake-up call to get your notes in order now. So:

• Be sure that each session note includes the ACTUAL therapy start and stop times. This may be the #1 thing the health plan is looking for — that you have evidence of the session length that backs up your billing.
• Make sure each note defends the client’s diagnosis and symptoms.
• If your sessions are 53 minutes or longer, discuss with any OPTUM clients who want a superbill whether to code as 90834 instead of the 90837. This would likely reduce their audit risk but decrease their reimbursement.
• Don’t let this scare you off from using 90837 routinely with most health plans. OPTUM and Medicare have the most extreme viewpoint of this code.
• Since your clients may not be reimbursed if your notes aren’t good enough to meet health plan requirements, get training now in documentation and treatment plans. I have three pre-recorded trainings that will give you the confidence you deserve in your documentation: “What’s Missing from Your Charts: Writing Great Notes,” “How to Write a 10-Minute Treatment Plan,” and “Audits and Records Requests — What Every Therapist Should Know.”  All are available here.