The Secret to Successful Treatment Reviews: Treatment Plans, and the Language of Medical Necessity

There’s a moment of dread in the life of many therapists when they get “the call”—it’s an insurance plan, asking for a treatment review. This article will walk you through the process in the hopes that I can minimize your anxiety and set you up for success.

What a Treatment Review Is—And What It’s Not

A treatment review is when an insurance plan contacts you to ask questions about your treatment. It is not an attempt to ask for their money back for past sessions, and rarely involves a request for records.  The plan is checking to see if they feel the treatment is necessary, and if they believe it is the right type, level, frequency, and duration. The plan’s goal is to decide whether they will cover additional treatment. It will usually be a phone conversation, though sometimes it will require filling out a form.

Treatment reviews are often confused with audits or records requests.

  • An audit usually refers to a documentation review. Insurance plans periodically (and usually randomly) choose providers and review charts to confirm that they’re keeping the kind of documentation that a plan requires. You can get a list of documentation requirements from any insurance plan you join. The good news is that an audit focuses solely on your charts and has nothing to do with your treatment.
  • A records request is also typically in regards to documentation, not about treatment. There are many reasons why you might get a records request, often having to do with complying with Affordable Care Act standards.

Can Non-Participating Providers Be Reviewed?

Most out-of-network clinicians don’t realize that their treatment can be reviewed at any time by an insurance plan.  I often hear, “I’m not even a provider for that plan, and they’re calling me for a treatment review. I never got involved with insurance because I never wanted my treatment reviewed! Can they ask me for this?”  

Unfortunately, they can.  As soon as your client submits an invoice to insurance for reimbursement, the plan has the right to look over the provided service and decide whether they feel it is covered service, and is being delivered at the right level and length.

What Can Trigger a Treatment Review?

When a therapist contacts me, panicking about a treatment review, my first question is, “are you seeing the client for multiple sessions a week?” Very often the reply is “yes! How did you know?”  Keep in mind that plans typically expect once-weekly sessions. Multiple sessions per week might be required if a client is going through some crisis, but after a couple of months, if you maintain that cadence, you may get a call from the plan to check on the necessity of this frequency.

For at least one insurance plan I know, the trigger is purely numerical: They review all cases where there are 20 sessions in 6 months.

Another trigger might be performing more sessions than average, given the client’s diagnosis. This means an Adjustment Disorder Diagnosis might get reviewed sooner than a Major Depression Diagnosis, as the latter might be expected to take longer to treat.  

However, for at least one insurance plan I know, the trigger is purely numerical: They review all cases where there are 20 sessions in 6 months.

Preparing For Your Review

When you get a message asking for a treatment review, it is tempting to avoid it.  Or you may just pick up the phone and “wing it” without preparation. I advise you do neither, but instead to thoughtfully and carefully prepare. You are less likely to be as nervous, and more likely to be successful. So, what should you do to prepare?

First, call the plan, and schedule the phone review, giving yourself enough time to prepare. While on the phone, ask for a list of questions you’ll be asked. Also, ask for their Medical Necessity Criteria they will use to judge the need for ongoing treatment.

Next, interview the client and ask the following:

  • What are your current symptoms? What is the severity of each?
  • How are these symptoms affecting each area of your life?
  • What is the status of risk factors or substance use?
  • What are your current psychiatric meds and dosages, and who prescribes them?
  • Are there any major health issues?
  • What progress have you made in therapy? What goals do you have yet to achieve?

It is also a good idea to administer  a quick assessment to have an objective measurement of a client’s symptoms and severity (ideally, do this throughout treatment, so that you can quantitatively measure progress).

Before the review, coordinate care with the client’s physician or other treating therapists, as the reviewer may ask if you have done this.

Make a list of answers to all the questions you’ll be asked. Focus heavily on listing observable symptoms (e.g., of depression, anxiety, insomnia) and how these symptoms are impairing the client’s life.

Make a list of answers to all the questions you’ll be asked. Focus heavily on listing observable symptoms (e.g., of depression, anxiety, insomnia) and how these symptoms are impairing the client’s life. This can be a challenge when your client is relatively high functioning, but look for even subtle impairments in all life areas including work, academics, relationships, financials, sleeping, appetite, and activities of daily living.  

Speaking the Language of Medical Necessity

The reviewer will be listening primarily for one thing: is the treatment medically necessary?  Each plan’s Medical Necessity Criteria varies, but typically they are looking for whether medical symptoms such as anxiety or depression are present. There needs to be a DSM diagnosis present or suspected (other than just a Z-code).  Treatment is not covered if it is solely for personal growth. They will also be trying to determine if the level of treatment is the best and most cost-effective (i.e., would this client be fine in a support group? Or would this client do better in intensive outpatient treatment?) Finally, they will want to hear that the client is improving in treatment.

The reviewer will be listening primarily for one thing: is the treatment medically necessary?

Remember that communicating with insurance plans is like learning how to speak a different language. When I talk to other therapists, we might talk about theory, how the mom and daughter are enmeshed or this client has an avoidant attachment style. When you talk to the insurance plan, you have to speak like a doctor about symptoms only.  

A Crucial Element of the Review: Your Treatment Plan

A key part of the treatment review is when the reviewer asks about your treatment plan. Yet some therapists don’t create formal treatment plans. It may feel time-consuming or confining. But treatment plans are not only mandated by some states and professional ethics codes; they can be a helpful guiding post for you during treatment.

In fact, some common reasons clinicians don’t get approved for more sessions after a treatment review are:

  • The clinician wasn’t able to articulate their treatment plan
  • The clinician failed to show the medical necessity for treatment in their treatment plan
  • The treatment plan was too vague in explaining how progress would be measured
  • The treatment plan didn’t include clearly articulated interventions

A Treatment Plan needs to include, at its very bones, three major components:

  • Treatment goals – These should be symptom-focused and measurable
  • Measurable objectives – This asks, how will you measure your goal?
  • Interventions

Many therapists did not get trained on how to create treatment plans. Thankfully, SimplePractice will soon offer the well-known Wiley Treatment Plans to help with this, which can make treatment planning both constructive and quick

Many therapists did not get trained on how to create treatment plans. Thankfully, SimplePractice offers the well-known Wiley Treatment Plans to help with this, which can make treatment planning both constructive and quick.

Tips for Creating a Treatment Plan

Treatment goals should be symptom-focused, and try to quantify it as much as possible.

“Reduction of anxiety” is a good goal, but “reduction of panic attacks from three times monthly to one time monthly” is even better. Also, make sure your goals are related to your diagnosis.

Set treatment goals with the client.

When a client comes to the intake, I ask them “imagine your last session, and that you got everything you wanted from these sessions. What will be different in your life? How will you be feeling/thinking differently? What will you be doing differently?”   

Make sure the goals are measurable.

If their goal is vague like “I’d like to feel happier,” ask “if you were happier, what would you be doing differently?” If the client said, “I wouldn’t wake to the alarm every morning feeling dread about facing the day, and I wouldn’t be dragging myself to work late.” — that’s perfect.

Improving sleep can be a great goal.

This is so common an issue, affects all life areas, and is easily measurable (ex. increase the average number of hours that they get per night). You can then name specific interventions that you do with insomnia as part of the treatment plan.

Interventions

These include things you do in-session, homework assignments, referrals, and recommendations. It is everything from suggesting a podcast or book, referral to a support group or for medication, or utilizing DBT, EMDR teaching progressive relaxation or mindfulness. It is not enough to say “my intervention is weekly individual CBT therapy.” No matter what your approach, chances are you “help clients identify how their cognitive distortions exacerbate their anxiety or depression and replace with positive affirmations.”  

Once you’ve put together a treatment plan, update it periodically during treatment.

Ask your client, “How are we doing with your original goals? Do we need to add new ones?” When reviewing original goals with clients, they are sometimes happy to hear how they have progressed. If no progress is being made on certain goals, you can discuss if new approaches are needed. Having the documentation of progress and your evolving Treatment Plan will help you to be prepared for a treatment review.

Don’t Panic

It’s understandable to feel anxious before a review, because your client’s therapy coverage is on the line. But let your anxiety motivate you to get skilled at speaking the language of medical necessity so that you can defend your client’s care.  If you understand what’s required, commit to preparation, and speak the language, you can ace an insurance treatment review.


Still a little uncertain? No worries!  Click for even more information on Medical Necessity and Speaking the Language of Insurance Plans, or you can also contact Barbara Griswold directly for help preparing for an upcoming treatment reviews or with insurance questions.

Also by Barbara Griswold:

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