You’re running a top-notch facility with highly-qualified clinicians and compassionate staff — you have a fail-proof operation, right?
Not quite. If your clinicians are not following documentation standards, you’re on the fast track to declined reimbursements, potential legal trouble, and ultimately, the failure of your treatment center operations.
To better understand the why behind the significance of clinical documentation, I sat down with Laurie Reid, a licensed Marriage and Family therapist, Certified Addictions Professional, and founder of Breaking the Cycle Consulting. For more than a decade, Laurie has worked in the field of behavioral health accreditation — she knows firsthand how valuable clinical notes are to the overall success of facility operations and client recovery.
Kelsey: Clinical documentation has always been an important component of smooth healthcare operations. What recent regulatory factors are pushing clinical documentation to the forefront of healthcare conversations?
Laurie: In the past, substance abuse treatment centers have operated in the private sector and self-pay world. Now, Affordable Care Act initiatives have set substance abuse as a disease and treatment centers are more involved in the world of billing to receive reimbursement from insurance companies. With billing comes documentation, and that documentation is what qualifies a treatment center to receive payment.
And it’s not necessarily the quantity of that documentation, but the quality of the documentation and making sure that it’s hitting on the points that insurance companies need in order to approve the days that a client is in your care.
Kelsey: Inherent in discussions related to reimbursement and billing is financial impact. How does improved clinical documentation affect a facility’s bottom line?
Laurie: The theory is: “if it wasn’t documented, it never happened.” So clinicians are documenting their services; however, they may not be documenting clearly enough to prove a certain level of care or medical necessity for the payment to come back into return. If a businesses is not training staff on proper documentation, based on the level of care criteria and medical necessity, then they are not going to get payment — even though they may be giving out great clinical care.
So that’s the bottom line right there. You’re not going to stay in business if your clinical documentation is not up to the standards of the insurance company’s requirements. Regardless of how credible and competent your clinicians are or how much your clients are progressing.
Kelsey: Aside from keeping your facility in business, why is documentation critical for patient care and what potential does it provide to improve treatment outcomes?
Laurie: In the behavioral health field, documenting symptomatology and what a client is presenting is crucial for receiving the clinical days that are necessary for that person’s level of care. For example, it’s not just “suicidal ideation,” it’s also “what’s going on with the symptoms of depression? Is it increasing? Is it decreasing?” And if we’re not documenting clearly, the person who is so desperate for a certain level of care will not receive it.
If we’re not taking a good faith effort in improving our documentation, and improving how we show the medical necessity for that person walking through the door, we’re not only failing the treatment center and the money we can get for sustainability, but we’re ultimately failing the client.
Kelsey: You’ve sold me on the importance of diligent clinical documentation, but clinicians are often dealing with demanding schedules. What tools can the business leadership teams give them to make clinical documentation easier, and how can they help clinicians understand the relevance of documentation?
Laurie: Absolutely — a lot of clinicians and business people are just overwhelmed. We’re trying to treat patients and clients that come in. We’re trying to navigate an entire day of schedules, and there’s an overwhelming burden on top of that of “how do I maintain and put an infrastructure on documentation?”
The number one thing is bridging the language divide. In my consultation with various organizations, and even when I was a quality manager teetering between both the administration world and the clinical world, I’ve found that the business team and the clinical team speak different languages. What any business can do, at the onset of new hiring, is train staff on documentation to bridge that language divide.
In terms of expressing the relevance of record keeping to clinicians, what I try to emphasize is that your status as an incredible clinician is truly dependent on what you wrote in your records. Documentation has always been a struggle for clinical teams because we look at it as “the magic happens in the room,” but if we don’t know how to describe or put a narrative to the art that we do with the patients in front of us, then we’re not really showcasing the ability and the importance of clinical care.
Kelsey: What strategies can treatment centers employ to bridge that language divide you spoke about and how can they make clinical documentation improvements a key part of their operational plan?
Laurie: I’m prior military, so I look at things from a structural, boots-on-the-ground view. We need to have someone that’s readily available to help out and review documentation and deliver the training that’s necessary. It’s also crucial that the c-suite level folks are emphasizing that clinical documentation is important enough to invest the time and energy into training staff.
From there, it’s about regulating and overseeing that documentation. Not just from a compliance perspective of “did they get it done, did they not get it done?” but from a qualitative perspective where someone else is peer-reviewing or a supervisor who understands proper documentation is reviewing. This requires a close relationship between clinicians and the utilization review (UR) department (or the outsourced billing company that you utilize) to really find out what is needed in clinical documentation and to make sure you’re hitting those points in your clinical notes too.
Kelsey: You’ve spoken quite a bit about clinicians needing to hit on requirements established by insurance companies. How do you envision the future of clinical documentation for a more collaborative approach between insurance companies and treatment providers?
Laurie: From a macro level, treatment centers; those who are owners of treatment centers; clinicians; even those who are in private practices, all need to be at the table with insurance companies to talk about how to move forward.
Right now, the insurance companies are dictating what the level of care is instead of the clinicians. Clinicians should be more involved because they are the ones who are seeing the clients face-to-face and treating clients. If we’re not documenting according to the clinician’s treatment plan and recommendations based on the signs and symptoms, then we are losing the care that is desperately needed by the client. It’s really going to take a meeting of insurance and clinicians to understand one another.
Kelsey: So how do we bridge that gap?
Laurie: We have multiple different conferences around the nation, yet, we’re not really inviting the insurance companies into our world or vice versa from the provider relations point of view. It’s imperative that we all sit at the table and start the conversation to bridge the gap. In the past, I have spoken with insurance provider representatives and connected by taking the approach of curiosity instead of a fighting stance. By curiosity I mean by asking questions such as: “so tell us how you got to this” or “what task force comes together and decides on the level of care” and most importantly “how can I get involved?”
Overall, clinicians, treatment providers and owners of treatment centers can make a difference by involving themselves in the insurance company’s world. For instance, we can ask to partake in their task forces or we can participate when provider relations representatives reach out. Our self-pay world is slowly diminishing and evolving more into an insurance-based payment models. It’s imperative that treatment centers are at the forefront of these insurance discussions.