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Abundant Practice Podcast
Episode #661: Avoiding Clawbacks - Private Practice Notes 101, feat. Dr. Tiana Kelly
00:29:56
, DSocSci, MA, LPC, NCC joins me to dive into the realities of HIPAA and insurance documentation in private practice—focusing on practical tips over legal jargon. She explores common mistakes like late notes and miscoding, and shares strategies for...
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- [00:00]
Alison Parear
Foreign hi, welcome to the Abundant Practice Podcast. I'm Alison from Abundance Practice Building. I have a nearly diagnosable obsession with helping therapists build sustainable, joy filled private practices, just like I've done for tens of thousands of therapists across the world. I'm excited to help you too. If you want to fill your practice with ideal clients, we have loads of free resources and paid support. Go to abundance practicebuilding.com Links all right, onto the show. Some of y' all aren't sending HIPAA compliant email and it's a problem. Even if you're paying for a business Google Workspace account and have a signed BAA, your emails still aren't 100% compliant. That's where Palbox comes in. You can connect Palbox to your Google Workspace or Microsoft 365 email one time and you're completely covered. No one has to sign into portals. It sends and it shows up like any other email behind the scenes. Powbox soft checks the security settings of the recipient and ensures that the email is sent properly so you're not violating HIPAA in the ways you may accidentally be. Now, I know HIPAA isn't sexy, but we don't avoid compliance in an Abundant practice. We check the boxes we need to check and this is the easiest way to do that with email. Check out my friends@powbox.com that's P A U B O X Use Code abundant to get $250 off your first year of powbox. That makes it less than $100 for your first year. Again, that's P A U B O X.com use code ABUNDANT so I've talked about TherapyNotes on here for years. I could talk about the features and the benefits in my sleep. But there are a couple things I want you to know about therapynotes that doesn't typically make it into an ad script. First is that they actually care if you like their platform. They don't only make themselves available on the phone to troubleshoot so you don't pull your hair out when you get stuck. They also take member suggestions and implement those that there's client demand for, like Therapy Search, an included listing service that helps clients find you internal and external secure messaging clinical outcome measures to keep an eye on how your clients are progressing. A super smooth super bill process, real time eligibility to check on your client's insurance. In my conversations with the employees there at all levels, they all really believe in their product and they want you to love it too. Second, they are proudly independently owned. Why should you care about that because as soon as venture capital becomes involved, the focus shifts from making customers happy to making investors happy. Prices go way up, innovation plateaus. Making more money with as little output as possible becomes the number one focus. With over 100,000 therapists using their platform, they've been able to stay incredibly successful. And they don't have to sacrifice your experience to stay there. You can try two months free@therapynotes.com with the coupon code Abundant. Welcome back to the Abundant Practice Podcast. I'm your host, Alison Parear. I'm here with Tiana Kelly and we are going to be talking about notes one on one. Your notes are really important. We know they're important. None of us are like super on fire excited about them. You're probably going to want to check out private practicebydesign.com after this conversation so that you can get some more of what Tiana's talking about. So thanks for being here, Tiana.
- [03:24]
Tiana Kelly
Of course, yes, thanks for having me. I'm super excited to dive into this conversation and like you said, you know, not the most glamorous or that we're not going to have the most fun time doing our notes, but, you know, talking about it and making sure that we're all practicing within best practice recommendations is, I think super important for our field, even when we don't like to admit it.
- [03:45]
Alison Parear
Yeah, absolutely. And I think right now I have heard from a lot of students who take insurance that there's kind of like across the country in the US a rash of clawbacks that have been happening and that's often due to documentation. So we really want to make sure that documentation is as buttoned up as it can be. Even though none of us are like, gosh, I wish I could do more of that. So what is like, what would you say are like the basics of what we absolutely need to have in every single note?
- [04:16]
Tiana Kelly
Oh, that's a really good question. So you know, obviously every, every EHR is going to set us up a little bit differently for what gets included in the note. But I think by and large the trends are like we, we want to have some data on like our observations. So you think about kind of that men status exam data. I think that that, that across the board is consistent for EHRs for how we were trained as therapists. You know, what are we observing from the client in terms of some of that mental status? I also think, you know, our, our payers specifically, if you're an insurance based practice, they want to see like what are the interventions we're using and how are those interventions connected to, like, the goal work? They want to see evidence that the goals are being worked on within the notes. What's the plan? What's the plan between sessions? What's the plan for, you know, if you have a tentative agenda for your next session? How are you going to follow up about some of the information that was maybe talked about at the last session? So that's kind of like the meat of, I think, the important pieces that need to be within notes within our documentation. Of course, there's like, the logistics, making sure that we're coding sessions correctly and capturing, like, accurate times within the sessions. So, yeah, I would say that in a nutshell, a really quick nutshell, that those would be some of the most important pieces to make sure we're focusing on.
- [05:45]
Alison Parear
And I think about, like, medical necessity. How do those things prove medical necessity?
- [05:50]
Tiana Kelly
Yes. Yeah. This is a big thing that I am working on within our practice to, like, strengthen our documentation around how we're trying to prove or give evidence to some of that medical necessity. Making sure that we're finding ways to justify what diagnoses we're providing. You know, making sure that we're. Sometimes it's going back and pulling out that DSM and looking at what. What criteria is the client giving me that matches a specific diagnosis? And then you use that DSM as your tool to write up that presenting problem. To justify. Yep, this is the diagnosis that I'm providing or to justify. Yep. These are the goals that need to be worked on. So, yeah, I like that you bring that point up because it is. It's a huge sticking point when it comes to insurance. And I think it does, if we do it correctly, help to really guide our work, our diagnosis, and our treat. Treatment.
- [06:39]
Alison Parear
Yeah. When I was coming up as a social worker, I went from doing, like, really arduously long notes that were basically like a rehashing of the entire session and one type of place. That's how we were kind of trained to do our notes to working at a sexual assault center and child advocacy center, where our notes were likely going to court in many circumstances. So they became very skeletal. And like, as long as I checked the boxes, we didn't. We were a nonprofit, so we didn't have to contend with insurance, but like to check enough boxes while maintaining enough privacy for the client. It was like this really intricate balance of being skeletal but also meeting the needs of what documentation is supposed to provide. Where do you fall on the skeletal notes versus rehashing of the session?
- [07:29]
Tiana Kelly
Excellent question. I love that you're bringing this up because it sounds like we have very similar backgrounds in terms of work and where we've gotten started. And I have my initial training, my internship was at a domestic violence, sexual violence agency. So we were very skeletal. And then I moved into partial hospitalization, and that was give me every single detail of every client every single day. So it is a really strong skill set you have to develop in order to get a little bit of both right. Keep the detail in there when it's relevant and important, but also cut out the fluff when you really just don't need it or when it might be a detriment to the. The client, to the client's safety, to the client's care. I. Whenever I'm working with clinicians, you know, in consultation about their documentation, that is the first question that I ask them, if I don't already know that about them, is, you know, give me a sense of where you got started in your practice, in your counseling practice. Because it does help me to understand when I'm in there looking at their files and if they have really scant documentation versus really, really wordy, giving me every single detail, a lot of times I can kind of trace that back to what their work experience have been thus far. You know, those ones that it's. There's barely any detail in there, they have had some kind of work experience, like in. In some, like, victim services agency. Which helps me then to know, like, okay, this is where this is coming from. It's not just because you don't want to do documentation. Like, we can kind of cut those judgments out if we just sit down and have a conversation around, like, what have your work experience has been, what has your training been like? And then how now that we're in private practice and our payers have their own requirements, how do we find a B between the two, you know, to honor, like, where you think it's appropriate to keep the details out, but also make sure that we're providing enough detail that we can, for instance, justify the treatment that's happening.
- [09:29]
Alison Parear
Absolutely. And I'm curious because we're so. We're talking about these different workplaces. Some are beholden to insurance companies, some are not. I think about this, the way some private payments clinicians approach their notes is kind of like, I don't really need to do this. Like, I'm not going to get audited by an insurance company and have to pay money back. What is the difference in documentation from an ethics perspective for private pay clinicians? Versus clinicians who take insurance.
- [10:02]
Tiana Kelly
So primarily when, when I'm consulting, I'm consulting with, thus far anyway, private practices that are insurance based. So I don't have too, too much experience working with the, the SEL pay. However, what I will say is, I think regardless of who your payer is, you know, if it's self pay, if it's insurance, if it's nonprofit, I think we need to look at like, what do we need to do in order to provide the best care possible. I think lots of people think that, that those notes in the documentation is for the payer. And yes, that's accurate, that is true. But I also have always taken the stance that like, this is kind of for me, this is my moment. Now. Do I always treat it so like, fluffy and positively? No. But when I, when I do find myself getting like, ah, so many notes, I need to get this done, I try to sit back and just think and reflect. Like this is for me to conceptualize what has happened within the session. Where do I think I'm headed next? Have I been checking in about the goals? Have I not, like, do I need to do a check in about that? So I think, you know, if every clinician could kind of lean more into that mindset of like this being more for us than having to follow all of these different requirements, I think that we would trend in a better direction in terms of documentation and just be more open to documentation. I think whether you're private pay, whether you're insurance based, like, you should be taking good notes because at the end of the day, like if something were to happen, if it wasn't written, you don't have a leg to stand on. So that in and of itself is like, this documentation is for you to make sure that you're protecting yourself in the event that, you know, something, something catastrophic or you know, even just something minor were to happen. You want to be able to have something to point to that says, hey, you know, this happened, we had this conversation, this was the agreement. Otherwise what are you going to do?
- [11:58]
Alison Parear
Yeah. So what are some common mistakes that you see people making in their documentation?
- [12:05]
Tiana Kelly
I think the biggest one is timeliness. And it makes sense, right, because we are seeing clients back to back to back to back to back multiple days in a row. And all it takes is that one day, you know, where maybe you're not feeling your best, maybe you're not as motivated, maybe you can't focus and suddenly you have, you know, six, seven notes, five notes even to start your next day and Then you know, you start the next day, you're getting behind and you know, we all know how that process can start and kind of repeat itself. So I think all it takes is just that, that one day and then we are behind and that can become a pattern. And also you know just for, for some it, they're, they're very good about getting those notes in within the you know, industry standard 24 to 48 hours. And for others like it's just, it's always been a weak point and that's okay. We acknowledge that we give the skills to work on time management improving that a little bit. But I would definitely say like timeliness that sticks out time and time again as one of the, the biggest errors or like weak points I think for clinicians as a whole. In addition to that I would also say miscoding. So if you are an insurance based practice, I think that this probably more often than not happens by accident. You know, just it is hard to keep track of time and how, how long was I in the session and documenting that appropriately. And did I, did I start right on time? Did I start two minutes later? Did I write that I started at 12:02 and not 12:00 clock or did I just leave it as the default? And then you know, if that session was 53 minutes did I code it as the 90837? If it was 52 minutes did I code that as the 90837? Right. Like right. We, I think we make those mistakes sometimes because we're just moving a little bit too fast. But there's also like the, the intentional. Yeah, it was 52 minutes and I'm going to code it as a 90837. Right. So just having to be super mindful and intentional about keeping track of time and honest reporting of our, our time and our duration spent in session. And you know, thirdly I would say biggest like error is just proofreading this. I, I am big on you know, proofreading, editing things before we put it out there. And I think especially so even though you know we're doing so many notes and lots of times like no one is going to read them besides you, I think it's super important to just at the very minimum give that quick glance over to make sure like do you at least have the client's name spelled right? If you're using clients name right, can, can we at least make sure that that's happening? But you know, lots of times we can catch just really silly errors and not that it has to be perfect 100% of the time. But can we. Can we catch the glaring stuff by doing a quick glance over?
- [14:52]
Alison Parear
Yeah. Can we talk about the risk involved with each of these things? Like, what's the risk involved with the timeliness piece? Like, let's say you're somebody who, like, most of the time gets all your paperwork done on Friday, but not all the time. Like, what's the risk that we're putting ourselves in?
- [15:11]
Tiana Kelly
Yeah, well, I think it's, you know, what you mentioned a little bit ago with clawbacks, that that is always a risk for many different facets of our documentation. If we're not doing it according to standard, insurance can come back and say, you know, hey, you didn't do this within the 48 hours or the 24 hours that we require. And so, you know, we. We want our money back for that session. I would say, you know, by and large, most therapists are like what you described, where they're getting their notes done, they're getting the documentation in on time. They might have a day or two here and there where it's like, oh, that it just didn't happen. And there, you know, there's still risk there. However, if I were in front of, like, an insurance company, there was an audit happening. I would point to, like, look, this is not a practice for this therapist. You know, clearly there was something going on that day to see if we can kind of like mitigate risk. Here's the things that we do to train our clinicians to be better with time management. Here's a plan that we could put in place with this therapist if this were to happen again. So always a risk that you carry. But I think that there is ways, even in those cases where, like, this isn't normal or common for a particular therapist and it just happened, and it just happened to be caught. I think there's still ways to try to mitigate the risk. If not for that particular maybe, like, session that's being audited, then in the future. Right. To mitigate the risks moving forward.
- [16:36]
Alison Parear
And I think about, like, the people listening who are group practice owners or the people who are listening who are in group practice. Like, it really does underscore how important that timeliness is. If, you know, I've worked with a group practice owners who had $30,000 clawbacks, and if the callback happened partly because notes weren't. Were turned in four days late or two weeks late, like, that's a. That's a ton of money that the practice no longer has and that they Might not be able to stay open because typ group practices don't have a huge profit margin. So, yeah, hopefully for anybody who is currently working in a group practice, that's a little nudge to get those things done. And for those who own the group practice, it's a reminder of, like, make sure your clinicians are doing that so that you don't get into a position where you maybe can't even keep your business open anymore.
- [17:26]
Tiana Kelly
Absolutely. Yeah. And I like that you throw in that perspective because, you know, as the clinician employed in a group practice myself, like, it gives me another level of respect for, like, my responsibilities. Like, this isn't just about making sure that I get a paycheck at the end of the day. Like, it is about the stability and viability of the practice as a whole. And, you know, if my employer has given me the opportunity to be employed here and have many opportunities within that employment, want to make sure that I'm doing what I can to help myself stay afloat, but to help the practice stay afloat, to help my colleagues stay afloat. Because you're so right, like, it just takes a few clawbacks and that could be the end of the business. Which is devastating.
- [18:13]
Alison Parear
Yeah, absolutely. I'm assuming similar risk for both coding and proofreading that, like, if you've miscoded and like, there's the coding that they're never going to know about. Like, if you went 52 minutes and you wrote that is a 90837, they're unlikely to know about that. But we gotta have integrity, you know, like, just go another minute or just do a 90834.
- [18:38]
Tiana Kelly
Yeah.
- [18:39]
Alison Parear
And so trusting that everybody listening has integrity. The coding errors and the proofreading problems could lead to clawbacks as like, the primary risk involved there.
- [18:52]
Tiana Kelly
Yeah, for sure. And I think, you know, I was just involved in a conversation yesterday, a consultation, just talking a little bit about, like, the, the miscoding. And it, it truly was just an error. Right. And what it boiled down to was, like, okay, in the future, like, like, let's just slow down. That's all it would probably take to just slow down before you hit that sign button, make sure that those numbers match. Like, yes, those seconds add up over time, over the day. But those seconds could really mean the difference between, like, we were just talking about, does the practice stay open or does it not? Do you stay employed or do you not? And that's not to last piece there is not to say, like, if you miss code, you're going to Lose your job. Like, I'm not, not, I'm not in charge of that for anyone. But part of what I do in my consultations is try to really like offload the fear. So I recognize that as like a very fear loaded statement. But I do think it's important to just consider like, yeah, how my, my quickness, my swiftness through my documentation when I'm not paying attention to maybe different errors that I might be making, how it could really have some detrimental outcomes. Likelihood maybe slim with the large volume of documentation being produced in a given day by, you know, any given practice. But still it's risk.
- [20:09]
Alison Parear
Absolutely. I'm thinking too about the whole private pay question. If you're doing out of network benefits, if you're sending people, like, if the super bill is getting to the insurance company, then you are required to meet their needs. Basically, if they're paying that client back for that session, they can call that back from the session from the client. If you are not doing the notes that you need to do.
- [20:33]
Tiana Kelly
Yeah.
- [20:34]
Alison Parear
So just putting that in there for folks. What else, what else are we missing with documentation that like, would make it better, cleaner, easier for everyone involved?
- [20:46]
Tiana Kelly
You know, I think I see a lot of times some of these errors being made, perhaps in part due to just like unclear guidelines. I think especially with into private practice, it's like, oh, what do I do? I remember having those questions when I started in group practice of like, I know how to write a treatment plan, but what's required? Like, I've only had experience in partial hospitalization. I've only had experience in nonprofit. So what do I need to do in terms of private practice? What do insurance companies want from me? So I think that is like 50% of the equation here where, you know, if you're in private practice, are you supplying your, your clinicians with like a roadmap or a blueprint for what do they need to even include in their documentation? Once you provide that, right. You get to say like you were given the, the criteria, you were given that blueprint and that is what is expected of you. I think the other like 50% of the equation is clinician confidence. You know, I think sometimes like that over documentation especially comes from like, like, well, I just don't know what to include.
- [21:54]
Alison Parear
Yeah.
- [21:55]
Tiana Kelly
And so I include it. All right. Or you know, the under documentation could be some of that too. Like I, I don't know what to include, so I just include the bare bones because I don't want to put in too much. And I think we need to fall back on. Like, we all go through extensive training to get in this position that we're in. We, you know, most of us are licensed or pursuing that licensure. We have to do continuing education. We know what we're doing. And I think a lot of times we get scared, especially when that word like compliance is thrown around, like, oh, gosh, they're going to do chart audits. And we get really nervous about are we doing the right thing or are we not? And fall back on your training. You've had extensive training and how to do this. You know how to do this. You have a clinical gut. Right. We talk about that. Like, trust your clinical gut. Does it feel like it needs to be in the note? Yes. Include it. Does it feel like it shouldn't because it might be a detriment to the client. Client's safety or well being, then no, don't include that. Right. So, yeah, I would say that, that, that is an important piece that I don't often hear talked about. Like just being able to trust yourself in what you are documenting and when you are really struggling. That's why we have supervision.
- [23:02]
Alison Parear
Yeah. And I think, like, I'm somebody who loves an example. I'm someone who loves a structure. Like when I worked in different places, who either did soap notes or burp notes and being like, could somebody just tell me which one to do? Like, I just, I don't care. Just give me a structure, give me an example. And I feel like that's missing. To my knowledge, I don't know of any insurance companies who provide that. Like, we expect your notes to look like this, but then they can pull our money back when we haven't done it the way they haven't told us how to do it.
- [23:35]
Tiana Kelly
Yes.
- [23:36]
Alison Parear
So how do solo private practice folks figure that out if they take insurance when insurance isn't telling us what we're going to get dinged for?
- [23:46]
Tiana Kelly
Yeah, I'm gonna give an answer. And I, I think people might turn off the, the podcast at this point, but I'm gonna give the answer anyway because it was what was most helpful to me and that is reading the insurance manuals.
- [24:01]
Alison Parear
Oh, God.
- [24:03]
Tiana Kelly
Yes. I know it's not the most fun reading, but it really does spell out everything that we need to include in there now in way too many pages. And with way doesn't apply to us. Right. Because they just hand us the whole manual, whether it's applicable to physical health, mental health. But if you, if you kind of sit down with those manuals, you will be able to create that blueprint for yourself. You will be able to create, you know, they need this and this and this. And the intake should include this. The treatment plan should look like this. And then, you know, you can kind of create those examples for yourself or a template or an outline or something of what each of those pieces of documentation should look like. But yeah, not the, not the prettiest answer there, but I think it is a tool at our disposal. Now, could insurance companies get a little bit better at providing us with, you know, a one pager, A good example? Yes, I would advocate for that 100%.
- [25:03]
Alison Parear
Yeah. Yeah. It's almost like they're just fine with it being obtuse. Yes. Yeah. Which they make more money that way. I get it.
- [25:12]
Tiana Kelly
Yeah. Yeah.
- [25:14]
Alison Parear
All right. Anything else we're missing around document. Oh, AI notes. What is your opinion on AI notes?
- [25:21]
Tiana Kelly
Oh, yes, this is a, a hot topic right now. You know, I think we, we just don't know enough. We don't know enough about where the data is being stored. We don't know enough about what happens to that data. We don't have training in how to sit down. And if, you know, if we are going to use some sort of AI software to produce the note. Like I've seen it done in action, and it's pretty scary how one sentence can turn into an entire progress note. Right? Like you feed it one sentence and it, it automatically tells you like all of these details. That's like, how did it know anything? And it's obvious that we should go back and make sure that we're looking to see that those things are accurate. But also without the training, we can't assume that people would know to go back and make sure that those details accurate. So I personally am kind of taking a firm stance. You know, until we know more, it's probably not the best to be integrating in. Until we have access to training, it's probably not the best to be integrating in. And if you have had access to training, then, you know, then. Okay. I just myself haven't come across any or feel comfortable doing that myself or recommending that to other people because we just don't. We don't have regulation around it at this point in time.
- [26:41]
Alison Parear
Yeah, yeah. And I think about how it comes back to the timeliness, the coding, the proofreading. Like, the proofreading is a really important piece because like you said, one sentence can be taken way into left field. And I mean, I don't know how good AI is. And if it can distinguish voices between People who have very similar voices or whatever, you know, like how it works. So just making sure if you are somebody who's using AI that you're not just copy pasting into your ehr or not just hitting accept if it's within your EHR that you're reading it and you're making sure that it hits all those pieces that we talked about, making sure that it talks about the time you start and end, making sure that it talks about medical necessity, the person, how the person's goals are being worked on through what treatment modalities or interventions. Because I mean, it just depends on the AI. I'm sure that some can do that for you, but you still need to make sure that what they say happened in session happened in session.
- [27:41]
Tiana Kelly
Yeah. And I think it's obvious anyway going to continue trending in that direction, building more AI into EHRs. So it's kind of like a here to stay situation. And I think you're highlighting about the importance of reviewing the note is kind of the equivalent to, you know, up until this point we've been writing the notes ourselves. And like I mentioned earlier, that for me anyway is kind of my time to conceptualize the case. At the very minimum, we, we need to be reviewing to make sure we have all of these different pie, but also to continue conceptualizing the case, to continue thinking about what is even happening in this client's treatment. Do they still need treatment? Right. These are questions that should be floating around in your mind as you're doing, you know, note after note, treatment plan after treatment plan for clients.
- [28:29]
Alison Parear
Yeah. Amazing. Thank you so much, Tiana. I feel like this is like very actionable. So yes, I would love people to take this and like, like take care of themselves notes wise.
- [28:41]
Tiana Kelly
Yes, yes. That's the hope. That's the hope. And if you read the insurance manual in the process, then I guess my job is done here.
- [28:48]
Alison Parear
Yeah. Amazing. Yeah. And our condolences if you do.
- [28:53]
Tiana Kelly
Yes.
- [28:54]
Alison Parear
Hope you do. A cozy tea. Awesome. Well, thank you so much. And yeah, if folks want to get in touch, private practice by design.com is where they can get some more. So thank you so much.
- [29:07]
Tiana Kelly
Absolutely. Thank you so much for having me.
- [29:11]
Alison Parear
Make sure your email is actually HIPAA compliant with Palbox. Use code Abundant to get palbox for less than $100 your first year at paox.com if you're ready for a much easier practice, therapy Notes is the way to go. Go to therapynotes.com and use the promo code abundant for two months. Free.
- [29:33]
Tiana Kelly
Free.
- [29:36]
Alison Parear
If you're listening. You probably need some support building your practice. If you're a super newbie, grab our free checklist using the link in the show notes. I'd love for you to follow rate and review, but I really want you to share this episode with a therapist friend. Let's help all our colleagues build what they want.