Myth: Your psychotherapy notes are kept for the good of your client and to help remind you of the issues discussed in sessions. Therefore, you can set up your chart notes however you think best suits these needs, and no insurance company can tell me you how to chart.
Fact: Insurance carriers and managed care companies have a right (by the contract that you signed if you are a provider) to audit your charts. If your notes do not meet their record-keeping criteria (regardless of the quality of service you provided) they have a right to request a refund of their payments to you. Furthermore, you cannot then bill the client. You are simply out the money.
Government programs, such as Medicare, also have charting standards. The Medicare Recovery Audit Contractor (RAC) Program was set up to reduce fraud and waste in the system. RAC agencies audit patient charts for inconsistencies, and are paid a commission based on what they collect.
One of our colleagues, a psychologist who specialized in working with elderly clients, was audited under the RAC program, and had to return $5000 to Medicare, because of “inadequate charting.”
Moral of the story: Find out exactly what the payor expects in your charts and chart to their requirements. That is the safest way to hold onto your hard earned cash.