Scary Trend: More Health Plans Requesting Your Notes Before Payment — Or After
by Barbara Griswold, LMFT
(February 8, 2021)
- Not getting paid for sessions we have already provided, and
- Getting paid for sessions we have provided, but then having the insurance plan ask us to pay the money back.
There are many reasons why a plan might ask to see your records that don’t have anything to do with payment (ex. Risk Adjustment Audits, general documentation audits).
But why might a plan refuse to pay or ask for money back?
- Your client didn’t pay his insurance premium, or is no longer with that plan. While this can lead to a claim denial, it doesn’t usually lead to a request for notes.
- Double-Coverage: Your client has another insurance that they failed to tell you about. Without knowing this, you billed the “secondary” insurance, who didn’t catch this double coverage issue until after they paid you. The secondary plan now wants you to pay them back while you bill the “primary” insurance. (Note: while this can lead to a request for repayment, it doesn’t usually lead to a request for notes).
- You’ve tripped an “audit trigger”— you may have
- billed for an unlikely/inaccurate billing code, diagnosis code, or number of units.
- billed for a high number of sessions in one week/month.
- regularly billed for Prolonged Service codes for extended sessions
- used a high number of sessions for that diagnosis
- they have reason to believe you are using individual therapy CPT code 90837 for couples therapy
- You’ve billed OPTUM/UBH/UHC using CPT code 90837 regularly: With this health plan, billing CPT code 90837 (60 minute individual therapy) may put you under additional scrutiny, since their provider manual states that that code is seen as necessary only for complex cases or specialized types of treatment that may take extra time (ex. EMDR, Systematic Desensitization, etc). They may want to see your notes to back up the need for that code.
10 Tips to Prevent Denials and Paybacks
- Submit claims (or have clients submit invoices) as soon as possible after a session. This helps you discover some problems earlier.
- Be sure you ask clients about all possible coverage, and check coverage before starting treatment.
- Document each session in a timely fashion. Remember, it may be fraud to write, rewrite or backdate notes. Having no note — or no good note — can equal no payment.
- Document your interventions. Sometimes we document the client’s problems but forget to mention the service we provided. One health plan refused to pay for sessions since the therapist had not documented interventions in the notes.
- Document improvement/progress. One therapist was asked to pay money back to the plan due to several missing items, including “failure to document the progress or improvement of client.”
- Document ACTUAL start and stop times for each session, not scheduled times. This should NOT include time spent waiting for a client, your lateness, scheduling the next session, or note-taking. Especially if you use CPT code 90837, plans want to see documentation of a session 53 minutes or above. If the session is 38-52 minutes, you’ll need to bill for 90834.
- Check your diagnosis codes at www.icd10data.com before using them to be sure they are still active. Type it into the search bar, then look for the green triangle next to the code.
- Make sure ongoing couples/family therapy is billed with CPT code 90847.
- If you are billing UBH/OPTUM/UHC for 90837 weekly, I’d think twice, or at least have extra-good notes.
- Take my pre-recorded webinar “What’s Missing from Your Charts: Writing Great Progress Notes”, which will tell you exactly what insurance plans want to see in your records, show you sample notes, and make you completely confident if your notes are requested.
Schedule your consultation with Barbara to get feedback on your progress notes or help with audit requests or other insurance questions — click here