Qa Prep Blog Insurance Records Requests--Rules to Remember

Here's a question I get all the time:Can insurance companies request my records?Sometimes it's asked a different way:Do I have to submit records if an insurance company requests them?This applies to anyone whose clients use insurance to pay for treatment, and that's often what mixes people up. So for those of you who submit superbills, this post is still for you, so keep reading.The answer, in case you're wondering, is YES.If an insurance company is paying for counseling or therapy, they can absolutely request records. They can request the entire record if they want, they can request copies of notes, they can request a summary-it runs the gamut. They can ask for as much or as little as they want.The pushback I hear from therapists is that it feels wrong, or it feels like an injustice, because we are worried about client confidentiality. That's a valid concern!However, what we as therapists need to address, is that it is part of our job to know this is a risk when clients use insurance to pay for services, and therefore it is our job to inform our clients. So as soon as you contract with an insurance company, you need to make sure that your intake paperwork and everything you go over with clients includes the information that insurance companies can request records and you can talk to them (insurance companies) and give them updates, and then you need to make sure you're covering that info with your clients in person.Making the very real possibility of records being shared will often push client to pay for therapy themselves rather than use insurance, because they realize they may not want their insurance company to have access to all that information.It's also important that you tell your clients that you are required by insurance to provide a diagnosis, so they know they will have a mental health diagnosis on their record, and their insurance company will know that.It's also important to know that if you aren't contracted with an insurance company, but your clients sometimes request their superbill to send over to their insurance company themselves, you still need to be having the conversation about confidentiality with them.So unless you refuse insurance completely and never provide superbills, I suggest you always cover the possibilities of insurance records requests with all of your clients to make sure you're covered and the clients know the potential outcomes.Another thing related to this is the diagnosis.And this brings us back to what I mentioned before, that clients should know they'll have a diagnosis on file. We all know we have to provide a diagnosis if insurance is paying, right? They require a diagnosis to establish medical necessity for treatment. They key here is making sure your clients know they will have a mental health diagnosis on file AND it's important that you consider what that mental health diagnosis is.It is considered insurance FRAUD- illegal, unethical, something that could lose you your license-to give an inaccurate diagnosis.What does accurate diagnosis mean?It means that if a client has a "severe" diagnosis, that you don't under-diagnose them. For instance, not wanting a client to deal with stigma of bipolar disorder, so diagnosing them with adjustment disorder instead. Read more in this blog about common diagnosis issues.This also means that if a client doesn't meet the criteria for diagnosis, insurance companies won't pay for therapy, and it's illegal to give them a diagnosis (like adjustment disorder) if they don't fit the criteria. So you should have a note in your paperwork that clients who do not meet a diagnostic criteria can't bill insurance.If you're still not sure you understand this, please educate yourself! Check out my free crash course where we talk about insurance as well as notes. And check out Navigating the Insurance Maze by Barbara Griswold.