What Should Your Notes Include When Insurance ISN’T Being Billed?
By Barbara Griswold, LMFT (July 5, 2019)
If you don’t work with insurance (or if a particular client is not seeking insurance reimbursement), you may wonder, “What do I REALLY need to cover in my progress notes when insurance isn’t involved?”
My answer is, “there should be no difference between the notes you take for an insurance client and the notes you take for a private-pay client.” Why?
1. Remember, even if you are not a network provider, clients with PPO or POS plans could later ask for an invoice and seek reimbursement for your sessions. Once an invoice is submitted, the plan could ask for details about treatment, or even to see your notes to support the need for treatment.
2. You may feel if you aren’t working with insurance you shouldn’t need to document the medical necessity of sessions. But legally and ethically, our notes should always reflect why sessions are necessary. This includes the symptoms being addressed, the details of the interventions and treatment provided, and how the client is responding and progressing. This is the heart of what any medical provider must document.
3. Some state laws and professional association ethics codes require treatment plans for all clients — not just insurance clients.
4. Your detailed notes may be your best defense should a client file a complaint with a professional ethics committee or licensing board.
5. Licensing boards can (and do) audit records, and cite you for missing areas. If you have covered the 10 Progress Notes Requirements outlined in my Client Chart webinar, you will likely have met most licensing board requirements.
6. Your detailed notes may be essential when helping a client get approval for deserved disability or work leave.
The bottom line? Illegible, vague, or superficial notes may hurt you and your clients — whether insurance is involved or not.
For help with your questions about insurance, progress notes, or practice building, contact Barbara Griswold, LMFT, author of Navigating the Insurance Maze: The Therapist’s Complete Guide to Working with Insurance — And Whether You Should at www.theinsurancemaze.com/contact
Read other helpful articles like this at www.theinsurancemaze.com/articles