How to Write Counseling Clinical Notes: Working with Insurance Companies

Dr. Centore,

I just read your article from 2013 in Counseling Today. I started taking insurance for the first time in November and I am constantly worried about whether my SOAP notes are adequate. It is almost to the point that I want to just stop taking insurance altogether… Not because of payment; they pay on time, but because worrying about this is stressful. Do you have a resource or article you could point to, or some advice, that would be a Gold Standard?

I just want to get this right.

Thank you for your consideration and time.

Sincerely,

Greg
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Greetings Greg,

Your anxiety is not unusual. It feels like a giant liability to have clinical notes that an insurance company might–at some later date years down the road–say are deficient in some way, and then might demand repayment for services provided.

That’s a nightmare. And, in fact, it does sometimes happen.

I know of a practice that got ‘dinged’ because they didn’t write in the note the length of the therapy session, which was 45 minutes. They billed the code for 45-minute sessions exclusively, and they figured since they billed that code they were attesting “these are 45 minute sessions.” But alas, the insurance company stated that since they didn’t also write in the note “this session was 45 minutes” they were due money back.

So, be vigilant, but don’t be fearful.

There are several books on Amazon that dive into clinical / medical notes from the 3rd party payer perspective. I’d recommend reading one or two of those. Also, some insurance companies offer medical note standards / guidelines. They can be exhaustive. Here’s one page from Anthem: https://www.anthem.com/wps/portal/ca/footer?content_path=shared/f0/s0/t0/pw_b133941.htm&label=Medical%20Record%20Review%20Standards&rootLevel=0. Next, if you’re using an EHR / EMR / Electronic Medical Records system, they might have information for you–and they might have worked a lot of the “what insurance companies want” into their notes templates.
I realize this response won’t answer your question fully–I don’t think I could give you a full answer as different insurance companies / payers might want different things, and those things can change again based on the services you’re providing. All this said, I wouldn’t go cash-only because of documentation woes. If anything, working with insurance might keep you on the straight and narrow to make sure your notes are done thoroughly, and timely. Good luck!