The Answer to Audits: Documentation

Paul Berman, Ph.D. MPA's Professional Affairs Officer

February 24, 2022 12:00 pm - 1:30 pm

1.5 CE Credits

Online via Zoom

Audit letters from insurance companies are anxiety-provoking. Insurance companies and other payors audit the records of in-network and out-of-network practitioners for a variety of reasons including, whether treatment (in their view) is medically necessary, whether a specific treatment process (type, frequency, length of session) is necessary and/or appropriate (from their point of view), whether proper codes were used, and for the purposes of a Risk Adjustment Audit (federal requirement that insurers assess the health of their subscribers for payment purposes), among other reasons.

Proper documentation is key. Insurance companies rely on the medical record to answer their questions. We will discuss record-keeping including informed consent, progress notes, psychotherapy notes, and treatment plans, and other important documentation. We will also review some relevant federal and state law including the federal rule (“Open Notes rule”), effective April 2021, which requires that healthcare practitioners give their patients access without charge to all the health information in their electronic medical records “without delay.”

 After attending this workshop, attendees will be able to 

  • Discuss different types of insurance audits
  • Write progress notes to meet audit criteria
  • Explain minimum necessary rule
  • Compy with the Open Notes Rule 



Paul C. Berman, Ph.D., is a licensed psychologist in private practice in Towson, Maryland. His practice focuses on family law matters including child forensic evaluations, custody evaluations, fitness to parent evaluations, domestic violence evaluations, sexual abuse evaluations and parent coordinator work. Dr. Berman was also Director of the Towson Addictions Center until 2019 and provided comprehensive assessment, education and treatment services for individuals with alcohol and other drug related problems. In addition to his private practice, Dr. Berman has been actively involved with legal, ethical, and legislative issues related to the practice of psychology. Since September 1993, Dr. Berman has worked part-time for the Maryland Psychological Association as Professional Affairs Officer. He serves as a liaison for psychologists with managed care/insurance companies, State agencies, and other professional associations.