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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.


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