Scary Trend: More Health Plans Requesting Your Notes Before Payment — Or After

by Barbara Griswold, LMFT

(February 8, 2021)

I have been providing consultations for therapists nationwide for over 15 years. In doing so, I’ve learned that there seem to be two issues that are high on the list of things that worry therapists:

• 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.

So, when you get a letter saying the plan is requesting more information from you before paying for claims you have submitted, or even after claims have been paid, this can be chilling.

“Does this really happen?” Unfortunately, yes. It isn’t common, but it seems to be happening a bit more than it used to.  And I’ve seen it lead to requests asking for the repayment of thousands of dollars.

“But Barbara, I ‘m not an insurance network provider!”  I’m sorry to say, this even happens to those of us who don’t have a contract with an insurance plan.  It only takes a client submitting an invoice/superbill to the health plan. I heard from two out-of-network therapists this week that their clients did not get reimbursed for statements they submitted because the therapist’s notes did not meet insurance plan expectations.  You can imagine how badly the therapists felt.

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?

1. 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.
2. 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).
3. 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
4. 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

1. Submit claims (or have clients submit invoices) as soon as possible after a session.  This helps you discover some problems earlier.
2. Be sure you ask clients about all possible coverage, and check coverage before starting treatment.
3. 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.
4. 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.
5. 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.”
6. 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.
7. 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.
8. Make sure ongoing couples/family therapy is billed with CPT code 90847.
9. If you are billing UBH/OPTUM/UHC for 90837 weekly, I’d think twice, or at least have extra-good notes.
10. 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