Maximizing Coverage through Clinical Documentation

As clinicians, we are taught many things about documentation. Most of us are taught it to put the least amount of information necessary to ensure the client’s process is protected. However, with an increasing number of consumers wishing to utilize insurance this is often a double-edged sword. 

Most insurance carriers have a set of criteria that they follow to determine what level of care and how much care they will authorize. Some carriers use ASAM criteria, some use a combination of different guidelines, and some have developed their own set of criteria which can be confusing to navigate (looking at you UBH). Here are some tips we’ve come up with to help clients be able to access their benefits in an honest, ethical manner:

  • 90% problem, 10% progress: While we want to be able to document the progress our clients are making this can work against them when it comes to insurance. A good guidelines is to document 90% to the problems the client is still experiencing and why this justifies the need for ongoing care. It is important to include some progress which is why we recommend the 10% guideline.
  • Be specific about symptoms: A natural inclination for clinicians is to note that client “appears depressed” or “stated they were anxious”. Most insurance companies want to know how this is determined. As a rule of thumb, it helps to include at least three observable symptoms and to use the statement “as evidenced by” when describing observations. It can also be helpful to ask scaling questions and to record the client’s report. Don’t be afraid to consult your DSM to familiarize yourself with diagnostic criteria.
  • External factors matter: When documenting rationale for ongoing care, many people often forget to include why a client returning to their home environment is detrimental. This is an important factor! If a client with SUD returns to an environment where most people drink and use it is antagonistic to their recovery. The treatment team may know but the insurance company will also want to. When working with mental health clients it’s important to gain an understanding of their support system’s understanding and attitude toward mental health disorders.
  • Use power-words: Using the phrase “the client’s home environment is antagonistic to their ongoing recovery as evidenced by…” reads more compelling than “client does not have a supportive home environment”. Describing a craving with a numerical value and in-detail (“client reported she could taste the powder in the back of her throat") is more compelling than “client continues to experience high cravings”. Help the reader understand the reality of the client’s situation and compel them to understand why treatment is needed.

At AVA, we spend time studying insurance carrier guidelines to be able to present the necessary information to justify and optimize a client’s ongoing care.   If you are interested in learning more about increasing your authorizations, give us a call.

Fraud & Abuse

2016 was a game changer in the field of Behavioral Health. We have quickly become one of the most costly business units for Insurance Carriers. In turn, carriers and government agencies are uncovering incredible amounts of fraud and unethical practices. What does this mean for your facility? Have you gotten inquiries from insurance carriers wanting to audit your claims?

Call AVA to schedule a free consultation and let our expertise work for you.


Blue Cross/Blue Shield Health Index

Has your facility wondered why insurers continue to squeeze Treatment Provider's reimbursements? Did you know Substance Use Disorders are in the top 5 most financially impactful medical conditions insurance carriers face, as reported by The Blue Cross Index. Substance Use Disorders now rank alongside depression/anxiety/mood disorders; hypertension; diabetes; and high cholesterol for most costly medical issues.

AVA can help in making sure your organization is setup in a manner to ensure proper payment from insurance carriers, maximizing your reimbursements, and more. Give us a call for a free consultation today!

Medicare Audit on Therapy Claims

Have you or your treatment facility ever thought about what potential changes are coming from Insurance Companies? What about the outlook for reimbursement in 4th Quarter or 2017?

2016 has seen massive sweeping changes in reimbursement rates in the first 8 months alone. The transition from ICD-9 to ICD-10, changes in medical necessity criteria and accepted CPT coding have all impacted a vast majority of treatment providers. Changes like these will continue as the industry evolves.

Medicare has issued a review for 60 minute psychotherapy sessions as a potentially over used CPT code. What this means is that claims being submitted with specific CPT codes will likely begin being audited and/or red flagged for review.

Are you happy with the quality of information and customer service your current billing company affords you? Do they tell you when when reimbursement changes happen, or do you not find out until months later?
AVA is founded on the principal that, "We thrive, by ensuring you thrive". Knowledge, Information, and Honesty are some of the principles of which AVA was founded on.

Original Article

Providers Steering Clients to Obamacare

This article contains important information for any facility accepting medical insurance as payment for services. Reports state that the federal government has launched investigations into healthcare providers steering and/or assisting patients into Healthcare Exchange policies when oftentimes the patients qualify for Medicare or Medicaid.

Steering patients to specific policies, insurance plans, or markets drives up healthcare costs. In turn, higher costs equate to increased premiums and increases the cost of coverage for all. With health insurance, if the risk pool gets to diluted with sick or treatment seeking people, insurers begin to experience great losses. As a result, insurers begin to pull out of markets (i.e. Obamacare Exchanges). We have already been seeing this all across the USA. Healthnet has pulled virtually all of its PPO policies off the Healthcare Exchanges. Aetna and United Healthcare are pulling out of most all exchanges as well.

Treatment providers may wonder, "How does this impact my business"? In the short-run, it may not. However, it boils down to simple economics and will surely impact us all. Less people have access to quality Drug and Alcohol Treatment because they no longer have viable private health insurance. A smaller "qualified" demand pool paired with a flat or increasing supply of rehab beds means times could be getting much more lean in the very near future.

If you have questions about the efficacy of your current insurance billing processes, maximizing your revenue in an honest and ethical way, or ongoing changes with insurance, Give AVA a call today! (888) 502-2826

Original Article located at


The Business of Health Insurance

The Health Insurance Exchanged launched in 2014. Since it's launch, insurers have been struggling to maintain reasonable margins. Major carriers are posting astronomical losses. This in turn is effecting insurance premiums for the working class. 

Lets take a look at North Carolina, For the insurance companies doing business in the state–the ones issuing policies to those 600,000 people–Obamacare has turned into a financial sinkhole. UnitedHealth Group, the nation’s largest insurance company, is pulling out of the Obamacare business in North Carolina next year. Blue Cross Blue Shield of North Carolina, which dominated the individual market with more than a half-million customers, reported that losses on its Obamacare business in 2014 and 2015 topped $400 million. The insurer said that figure includes government payments designed to shield insurers from big losses during the early years of Obamacare. The only other current competitor, Aetna, wants to hike rates by nearly 25 percent next year.

Insurance Carriers are ultimately businesses. The need to have healthy margins often outweighs client care.  Understanding this can be advantageous to the provider rendering services. Learning to speak the carrier's language is key to navigating medical necessity criteria in this world of change.