Working in the Age of Managed Care

Don't trust your relationships and reputation
to anyone except another mental health professional

Making the decision to become a mental health provider was an easy one, Devotion to learning,, helping people with problems and maintaining the highest ethical values were the ideals that inspired you. Working as a private practitioner or part of a group offered the opportunity for self-directed growth and independence.

Be Sure To Document

Case record audits are rare
but be ready when they happen

We all maintain both clinical and other documentation on our patients and our encounters with them. The manner that we maintain our records must meet federal and state regulations and laws and, more and more often, health plan requirements.

It is relatively rare for charts to be audited for actual clinical reasons but audits to make sure that all legal and health plan requirements are met have become more common. Chances are that the companies you do business with must pass guidelines from NCQA (National Committtee on Quality Assurance) and, more rarely, JCAHO (Joint Commission on Accreditation of Healthcare Organizations).

When you trained as a mental health professional, documentation was considered essential. Since then, the field and it's needs for health plan documentation may have changed.

Below is a simple summary of some rules of the road to follow in documenting the care you give your patients.

Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s care including the past and present illnesses or problems, evaluations, tests, treatments, and outcome. The medical record chronologically documents the care of the patient. The medical record should be complete and legible. Proper documentation facilitates:
* The ability of the mental health professional to evaluate and plan the patient’s immediate treatment, and to monitor his/her mental health status and care over time.
* Communication and continuity of care among the mental health and other health care professionals involved in the patient care.
* Accurate and timely claims review and payment.

Basic Principles of Documentation:
Documentation for each patient should include:
* Chief complaint and/or reason for mental health care.
* Relevant history, evaluation findings and prior diagnostic or treatment results.
* Assessment, clinical impression or diagnosis and plan of care.
* Dates and legible identity of health care professionals.
* The CPT and ICD-9-CM or DSM-IV codes reported on the health insurance claim form or billing statement must be supported by the documentation in the medical record.
* The confidentiality of the medical record should be fully maintained consistent with the requirements of medical ethics and of law.