How This Book Came Into Being:

A Lesson in Making a Really Bad Negative Into a Really Good Positive

In 1991, I started a solo mental health practice with no clients, very little money, no office furniture, and no formal business training. However, I had a surplus of enthusiasm and dedication. I found a three-room office suite that had been vacant for over a year, so I figured that I could get a fairly good deal on the rent. The sympathetic, but also hungry landlord and I worked out a deal in which I wouldn't have to pay rent for the first few months. He had nothing to lose because there had been no renters for over a year. He was glad just to have a renter. The furniture for the office came from my home. "Open for business!"

I did not take with me any of my clients whom I had seen from my former employer. I considered that to be an unethical practice. Instead, I transitioned them to other therapists when I left the practice. Of course, there can be exceptions to this rule, but be careful in such cases. I have seen too many therapists start their own practices by taking their clients with them from another agency. Over the years, I have witnessed many ill feelings between employers and ex-employees who "took their clients" with them, often without notice! This can cause much financial havoc for a clinic that has spent an incredible amount of time, money, and effort to build their practice. Bottom line: Cover such concerns in an initial contract with the employee or contractor. Be sure to use an attorney with plenty of expertise in this area. A relatively small investment up front could save your practice and reputation in the future. It can be difficult to have balance between being both in business and being in the helping profession.

To get started, I spent the remainder of my savings and much time establishing a counseling practice by scheduling talks with different groups, sending out mailers to several organizations, and letting other mental health professionals, with whom I had dealt previously, know that I had started a private practice. Many referrals came from other therapists who had a full case load, in which they were glad to have a place to send people in need of services. Even my previous employer sent referrals my way.

Fortunately, growth took place quickly, and within the first year there were two additional full-time employees. The rate of growth skyrocketed because we incorporated progressive, but ethical business principles and emphasized customer service. Now we could afford nice furniture at home and at the office!

Unfortunately, even though our clinic was on the right track, our quick growth caught the eye of an insurance auditor. Our rather sudden volume of business led to high payments from Medicaid. Because the amount of billing skyrocketed from nothing to quite high in a few years, we were a red flag for an audit. When I received notice of an audit I wasn't worried because we had records for every client and most likely underbilled rather than overbilled. So, a few weeks later, when the auditors showed up for their scheduled review, we were naively proud to show them that there were indeed their requested intake notes, treatment plans, and progress notes. I had written them the same way in which I was trained, so they must be pretty good!

The finding that complete records existed for every client and the rapid growth of the clinic was never mentioned as a positive by the auditors. We weren't sure what they were attempting to find in our client records. The auditors copied multiple files and informed us that we would hear from them in about a month. Because they gave us no immediate feedback, we weren't sure whether when they returned we would receive accolades or reprimands. But, we were quite confident that all was well.

For the next month, we did business as usual and didn't think much about the audit. However, when they showed up for the feedback session, our lives soon changed. The auditors informed us that there were no financial improprieties, and there were no records missing. We had not billed for any dates of service in which there were no records and we had not overbilled for any procedures. So far . so good. But, then they opened their briefcases with seemingly hundreds of progress notes in which they said were "not in compliance." My initial thoughts were, "not in compliance with what?" I was not taught a specific way to write progress notes in my graduate training, my internship, or my previous employment. I simply wrote down what we did in the session, just like at my previous job. But, they had never been audited! My problem was that I didn't know what I didn't know, which is commonly called "ignorance." The old saying, "Ignorance of the law is no excuse" was now staring me in the face. I soon learned that other old adage, "Ignorance is bliss," is not true.

The auditors kindly and respectfully explained that our progress notes stunk. Their point was that just because services took place, it doesn't mean that there is documented evidence that psychotherapy was necessary. They unsympathetically admonished me that psychotherapy records must document medical necessity. I had never heard of this term. It sounded like something someone would say in a medical office, not a counseling clinic. I thought to myself, "Medical necessity: We don't provide medical services." They went on to say that even though the assessments adequately explained the clients' diagnoses, the progress notes did not recurrently confirm the diagnosis, reflect the effects of treatment, follow a specific measurable treatment plan, and need for continued treatment. My progress notes merely documented that treatment took place with some comments of what took place in the sessions. This was not enough.

They explained to me that the documented content of each session must match the goals and objectives written in the treatment plan. I had never heard of treatment plan goals and objectives the way in which they viewed them. Their main point was that my progress notes for every session did not clearly describe ongoing symptoms and impairments that should be listed in the intake notes and treatment plan. That is, every progress note should validate the current need for services and the services performed must be appropriate for the client's problem areas. Even if a client is severely impaired mentally, if it is not documented in every progress note, there is no evidence for the need for psychotherapy. They repeatedly emphasized, "If it isn't written down it doesn't exist." I wasn't taught this in graduate school, nor in my initial employment.

I was told that I must pay back Medicaid the amount that I was paid for every progress note that did not meet this criterion. Although our treatment was appropriate and our clients' outcomes were positive, our progress notes did not specifically address medical necessity. Even if services were medically necessary, if it wasn't clearly documented, it didn't matter to them.

Our documentation covered the contents of the sessions only. Bottom line: We provided documentation; but it was the wrong documentation. Perhaps we should have spent more time reading their bulky manual. I was convinced that we provided life-changing mental health services, but the documentation didn't provide the evidence the auditors required. We had done nothing clinically, morally, or ethically wrong, but documentation is not about such skills; it is about supplying empirical evidence. Being a good therapist was not enough.

What surprised me even more was that they didn't ask for a payback for only the records that they had audited. They stated that because they audited one quarter of the records that I would have to pay back four times the amount of records that they had deemed not fitting their standards. Ouch!

This lack of appropriate documentation cost me several thousand dollars in paybacks to Medicaid. Fortunately, they put me on a payment plan; otherwise, we would have gone out of business. At the time the effects of this audit seemed like the worst thing that could have happened to me. I had no one to blame but myself. I couldn't tell the auditors that it wasn't my fault because no one had taught me how to appropriately document psychotherapy; because as a mental health professional it was my responsibility to be accountable for learning the procedures expected from me.

What surprised me, even more, was that the auditors weren't mental health professionals. They were trained in clerical areas. Although it took a while for me to make the connection, I eventually woke up to realize that if people not even trained in our profession can learn mental health documentation, I certainly had no excuses. This insight did not take place overnight!

The lessons learned from the audit inspired me to learn everything I could about documentation of mental health services. I studied information available from accreditation agencies, provider manuals from insurance companies, journal articles, and a few texts that existed at the time. With this information I revised our clinical forms to make sure that the information obtained accurately covered what was required. After sharing this information with colleagues, I was asked to present local seminars. This eventually led to presenting this material in several seminars nationally, teaching documentation skills. Before I knew it, my forms were published. The forms book is currently in its fourth edition (Wiger, 2010),...