How to Establish a Private Practice, Part 4: The Fine Print

As you probably know from your work experience, and coursework on ethical and legal requirements, therapists must provide specific information to potential clients and obtain the client's "informed consent" before initiating treatment. That means that clinicians starting a private practice have to have the necessary documents ready when their first client walks through the door.

What do you need?

1) Statement of Client Rights and Responsibilities

This statement should be available to the client to keep for reference, and you should also keep either a signed version, or an acknowledgment that they have received it.

Rights involve all the legal and ethical rights afforded clients, such as the right to participate in treatment planning, decline specific treatments or interventions, not face discrimination, privacy, confidentiality, and to file a grievance. Responsibilities can include maintaining behavioral control, providing accurate information, respecting the privacy and rights of others, participating in treatment, and/or stating whether or not they are willing to adhere to elements of their treatment plan.

2) Consent for Treatment

Clients demonstrate informed consent by signing this document. Therefore, it must contain several specific elements:

a) An explicit statement that the client consents to receive evaluation and/or treatment from you (or a particular clinician, practice, or agency), understands the potential risks and benefits, and that treatment can be discontinued at any time by either party.

b) A statement of the risks and benefits of therapy

c) Information on the Limits of Confidentiality

d) After-hours or emergency coverage policy

e) Clinician's credentials and contact information

The consent for should be signed and dated by the client, and witnessed by you or another staff person, e.g. if you happen to have a receptionist.

3) Notice of Privacy Practices (or Policies)

This has to be pretty specific to comply with HIPAA guidelines. The American Counseling Association has published guidelines (for the Notice of Privacy Practices, as well as Informed Consent, actually) that clarify what you should say. Feel free to take a look at mine, in the "Introductory Client Packet" on my website. Include signature lines for the client and witness to sign and date that s/he has received a copy of this information.

4) Financial Agreement

Technically part of informed consent, the financial agreement details your fee, whether you will work with the client's insurance company, when payment is due, fees for missed appointments and returned checks, collections, etc. The client, or whoever is financially responsible, should sign it.

5) Additional Authorizations

If you do plan to accept insurance, the client will need to sign something that authorizes you to file claims and receive payment on his/her behalf. If you may be reimbursed by workman's compensation, a similar authorization will need to be signed. Finally, parents/guardians will need to authorize the evaluation and/or treatment of any minor child.

6) Authorization to Release or Request Protected Health Information

Complementing the statement of confidentiality, and privacy policy, you should have a form that follows HIPAA guidelines for clients to sign to authorize you to contact other treatment providers. Many health insurers routinely expect that therapists have contact with clients' Primary Care Physicians, and psychopharmacoloists, if applicable. Get in the habit of asking for these releases up front.

Finally, many clinicians ask clients to fill out a registration or "face sheet" with contact information, insurance information, etc. Questionnaires about presenting problem(s), and/or standardized measures may also be given to clients to complete. This part is up to you, and based on clinical rather than legal/ethical grounds.

Am I forgetting anything? If so, please let me know!

Busy Work

These days, it seems like everyone is being asked to do more with less...less money, less time, less staff, etc. The only thing that seems to grow is the number of clients and productivity requirements! 

However, even as caseloads continue to climb, along with stress levels, I rarely hear colleagues complain about the time they spend with clients (except to say that they don't always have enough time for each client!). However, I do hear (lots of) complaints about all the other tasks that don't involve direct service - in other words, the busy work.

And there is a lot of busy work. Most of it involves documentation. In fact, just about every social work joke I've heard makes some mention of paperwork. Other kinds of busy work involve meetings, insurance red tape, and phone calls (especially the amount of time on hold, or wading through automated response systems before you get to talk to a real person). 

When it comes to documentation, I'll be the first to say that good records are important. Keeping records is necessary because it helps to ensure a high quality of care (if you have to record it, you're more likely to do it), while protecting professionals from liability (provided they are doing what they're supposed to do). It's also useful to maintain continuity in treatment, remember details, and update other providers regarding treatment that has been provided. 

However, all of these potential benefits of documentation are diminished as the volume and redundancy of paperwork grows. Basically, the more there is, the harder it is to find the useful parts, and the lower the overall quality tends to be (because it is more rushed). 

I had hoped that the trend toward electronic medical records would streamline documentation and minimize the volume and redundancy. However, thus far, I have not experienced that to be the case. Part of the reason may be that I live and practice in Massachusetts. Why, you ask? Because of the Massachusetts Standardized Document Project. Basically, a committee created a full set of mental health documentation (assessments, treatment plans, progress notes, etc.), which agencies have been encouraged to adopt. I believe the goals were twofold: to standardize forms so that, when someone's records are shared with a different agency, the receiving clinicians can make sense of them; and to ensure that documentation meets the standards established by the government and third-party payors. 

While it is hard to object to these goals, the actual product - the standardized documents - leaves much to be desired. The result of committee work is often to make things more involved or complicated, rather than simpler and more concise, for the simple reason that people disagree, and both sides get something included so that everyone will be happy. Of course, in reality, no one tends to be fully "happy" with the result, and that is certainly true of these forms. I don't know anyone who likes them! The psychosocial assessment is a full 12 typed pages, before adding 7 possible addenda (e.g., education, military service, trauma, legal, substance use, etc.). Any useful summary, diagnosis, or risk information is buried somewhere inside the stack, making it time-consuming even if someone else completed it! It has drastically expanded the amount of time I have to spend on paperwork, while making the result less useful for actual treatment.

I can't blame it all on the MSDP, however. My full-time job does not use it, but still has a ridiculous amount of paperwork, which is frequently redundant...and mostly hand-written, so you can't even cut and paste (the only saving grace when using the MSDP forms). Each client has to have 9 treatment goals, so most of the time we have to spend with each client is focused on updating these, rather than really meeting clients where they are.

I don't have an easy solution to all of this busy work, but I think a priority across agencies needs to be streamlining the paperwork, and other busy work, so that more time and energy can be spent focusing on the people we're meant to be helping. Time is a resource, and in this era of resource scarcity, we need to be better stewards of staff time.

"Smart" Treatment Plans

With the push to make mental healthcare more like medical healthcare, there is more pressure from payors and regulatory agencies to deliver measurable results using "evidence-based" treatments. Regardless of the many therapeutic processes and outcomes that defy measurement, we're expected to base our model of effectiveness on concrete, behavioral outcomes. Similarly, the Council on Social Work Education is requiring schools to evaluate students' performance using concrete, behavioral measures. I'm assuming there is a similar trend in other disciplines as well.

Setting aside whether this trend seems useful or appropriate, it does seem useful to know how to format documentation to fit what are these regulatory, accrediting, and/or funding agencies looking for - whether or not that actually carries over into how we work with clients (documentation certainly need not...interfere...with treatment!). Fortunately for us, there is a convenient acronym for how treatment goals should be worded: SMART.

S - Specific

Objectives should be specific. Instead of an overarching, general area of change (e.g., decrease depression), identify specifically what the client will do - what behavior s/he will exhibit (e.g., spontaneously smile in session). Remember that you're not trying to describe what treatment will involve, but rather how the person will behave differently if treatment is effective.

M - Measurable

There should also be some way to "objectively" measure whether the specified behavior is occurring (which is why they want us to focus on behavior rather than the harder-to-quantify outcomes and processes of therapy). Use of numbers is preferred, so think about something that can be counted (e.g., s/he will spontaneously smile in session 3 times), tested (e.g., s/he will score 10 points lower on the Beck Depression Inventory), or subjectively rated (his/her self-rating of mood will increase from 3 to 5 or more on a 1-10 scale).

A - Attainable

It's not very useful to set goals that can't be reached. They are discouraging, and also don't provide any information about whether expected changes are occurring. It also doesn't make sense to set goals that are too easily reached. They don't provide information about whether meaningful change is occurring. (They also make more work for us, since new objectives have to be created once the existing ones have been met). Instead, aim for the "sweet spot" in the middle - meaningful but achievable change.

R - Relevant

While some people use Realistic for the R, that overlaps quite a bit with Attainable. Instead, R generally stands for Relevant. In other words, the objectives should have something to do with the presenting problem, and/or something that the client identifies as personally important. To continue with the depression example, there are a wide range of behaviors that could be considered relevant, based on the diagnostic criteria: sleep, eating, social interactions, self-rated energy, motivation, or enjoyment, thoughts of death, etc, etc. However, if a client does not have a particular symptom (e.g., sleep disturbance), it would not be relevant to target that symptom in the objectives. It also would not be relevant to target unrelated behavior. And of course, it makes the most sense to start with what the client identifies as most important - whatever is motivating him/her to seek treatment in the first place.

T - Time-limited

Finally, there should be a specified time-frame in which the behavior change is expected and will be assessed. (Going back to attainability, the objective should be something that is reasonably reachable within the specified time-frame. Different settings and levels of care have different time-frame requirements - e.g., outpatient treatment goals are often reevaluated quarterly, while inpatient or partial hospital treatment goals are reevaluated weekly, or even more frequently. Going back to earlier examples, I might specify that the client will spontaneously smile in session 3 times by the end of the quarter, or that the client will rate mood at or above 6 on a 1 - 10 scale by the end of the week. (Note that not meeting the goal within the time-frame does not indicate failure; the time-frame is just an opportunity to reevaluate the goals, and whether they are attainable and relevant to current functioning and treatment).

Have you used this SMART model? What do you think about structuring treatment plans this way?

Things I Didn't Learn in School: Utilization Review

Utilization Review (or UR) is a fancy way of saying insurance review - it is the process health care providers have to go through to get health insurance companies to pay for treatment. While some internships provide an opportunity for students to learn this process, many don't (mine didn't), and it is certainly not covered in class curricula (which foster the illusion that being clinically correct is the only thing that matters). I imagine I'm not the first to tell you this illusion is false: clinical correctness matters...but only if you can convince a client's insurance company to pay for the treatment they need. If you can't convince the insurer, you won't be able to provide treatment, regardless of what your client needs (unless you happen to work with folks who are independently wealthy...).

While insurance companies claim that the purpose of UR is to ensure that their "members" receive the best care possible, we all know that a primary goal for the company is to contain costs. While they have an obligation to cover necessary services, they want to avoid paying for anything unnecessary, or ineffective. As a result, a primary focus of UR is the medical necessity of treatment. Most basically, you have to demonstrate that there is a clinical condition that is impairing the client's functioning and requires the recommended treatment (rather than a less-costly alternative). 

Classes address level of care from the perspective of ethical mandates to preserve clients' self-determination by providing treatment in the "least-restrictive environment" that allows for client safety and treatment effectiveness. In the UR process, however, level of care translates into cost: higher levels of care are more expensive. As a result, we have to make the case that the client would be unsafe, decompensate, or at least fail to improve at a lower level of care than whatever we're recommending. Even with a solid argument against lower levels of care, however, insurance may push back if the client has already exceeded expected/average duration of treatment at that level of care. 

That brings us to the trajectory of UR over the course of treatment. For most insurers, UR begins with prior authorization (also called pre-authorization, or pre-certification). Clinicians have to provide a diagnosis with supporting clinical evidence, make an argument for the medical necessity of the recommended level of care, and identify concrete treatment goals that cannot be achieved at a lower level of care. If the clinician has made a good case, the insurance company authorizes an initial number of days/units/sessions, depending on the level of care (e.g., days for inpatient, sessions for outpatient). Typically, the more expensive the treatment, the smaller the duration of treatment covered by the initial authorization; for example, I've seen an average of 3 days inpatient, 1 week partial hospitalization, and 8-12 sessions in intensive or standard outpatient.

Once the initial authorization has been used (or expires - they also have time limits), the clinician calls back to request additional time if necessary. They still have to demonstrate the medical necessity of this level of care, but also have to summarize what treatment has been provided, the client's response, goals for continued treatment, and the plan for discharge (e.g., a transition to a lower level of care). Obviously each concurrent review should show that the goals identified in previous reviews have been addressed, whether or not they have been met; if a goal has not been addressed, a solid reason should be provided. If medical necessity is unclear, or the client has already exceeded an average length of treatment, the insurance company may require a "doc-to-doc," where a physician employed by the insurer reviews the case with a physician or other licensed provider at the treating facility, and then makes a determination.

Once a client is able to be treated at a lower level of care, another call is made to the insurance company, summarizing the client's condition at discharge, verifying the total amount of treatment provided, and outlining the aftercare plan - what treatment will follow. This includes any outpatient appointments that have been scheduled, and in the case of a transition to any level of care other than standard outpatient, obtaining an initial authorization for that treatment.

Finally, some insurance companies will occasionally perform random audits of medical records to verify that treatment they've paid for was provided as described by clinicians, and was consistent with the contact between insurer and treatment facility. Medicare and Medicaid are most known for such audits, which are particularly crucial for Medicare because it does not conduct UR before or during treatment. Documentation is crucial to avoid owing money back to the insurer!

What tips do you follow for successful UR?

Things I Didn't Learn in School: Medical Necessity

Periodically, I will be posting on elements of practice that are important to functioning as a clinician, but weren't covered in my graduate school training. The first of these is: Medical Necessity.

For those lucky few who do not work with third party payors (i.e., health insurance companies), medical necessity may be a foreign concept. For anyone who hopes to receive third party payment, it's a vital part of case documentation. Basically, insurers will only pay for treatment that is deemed medically necessary. If you get audited and have not adequately documented the medical necessity of your services, the insurance company can refuse payment or require you to give them money back. Not a good thing!

So, what criteria determine medical necessity?

1. There must be a documented mental disorder - a DSM diagnosis with supporting evidence. For example: "Tim suffers from Major Depressive Disorder, with symptoms including increased sleep and appetite, loss of interest in his usual activities, isolation, loss of motivation, and feelings of hopelessness and worthlessness."
2. The mental disorder must cause significant functional impairment (if you check the DSM, you'll note that all diagnoses actually include "clinically significant" impairment in functioning as a diagnostic criterion). Possible functional impairments include educational, occupational and social functioning, judgment, and self-care or safety. For example: "As a result of these symptoms, Tim's occupational functioning is impaired and he is in danger of losing his job."

But, it's not enough to just document that the person needs treatment, based on the two criteria listed above. You also need to demonstrate that you're providing appropriate treatment:

1. Treatment provided must be consistent with accepted standards for the diagnosis and degree of impairment (e.g., someone with mild occupational impairment doesn't need an intensive outpatient program)
2. There needs to be a treatment plan showing how treatment will address the mental disorder and functional impairments, as well as behaviorally-worded discharge criteria.
3. Progress notes should demonstrate that the treatment plan is being applied. There should be evidence of both progress as a result of treatment (based on what is reasonable for the diagnosis), and continuing impairment to warrant continuing treatment.

Medical necessity can feel like busy work, or one of those annoyingly inconsequential things managers nag about. On the other hand, it can be an important systems of checks and balances to prevent abuse of the healthcare system. How do you see it in your own practice?

Reference: Wiger (2005) The Psychotherapy Documentation Primer (PracticePlanners)