Therapist completing EMR documentation

Why It’s Important to Systemize Your Therapy Treatment Documentation

As a therapist, you may feel like you’re drowning in documentation. You often have to finish up treatment notes and evaluations from home after a long day. If you’re completing them piecemeal — a bit at a time all day or all week long — you’re not going to be as efficient or accurate as you would if you had a regimented method. 

We’re fans of the flexibility that therapist life offers, but we also believe in creating predictable order when it comes to your professional processes. Following best practices in this area can save you time, protect you from issues that arise in an audit, and allow you to manage a full caseload while devoting your energy to quality time with your patients. Instead of letting documentation frazzle or exhaust you, we suggest systemizing.

What Does Systemizing Documentation Look Like?

First of all, it means creating habits around each documentation type. One example is to complete treatment notes at the same time of day (a free lunch hour or just after dinner) every work day. Another is to always fill in the fields on an evaluation or reevaluation in the same order. Presumably this way, you won’t forget any. Tasks that become habits are those you can stick with long-term.

Think ahead by reviewing patient charts, making a note of which patients have upcoming reevaluations far in advance (30 days) of the plan of care end date, and scheduling those appointments well before said date. Bonus: when you engage in this practice regardless of your clinic’s policies, you set an example for fellow therapists and show your clinic owner that you’re conscientious.

Systemizing also looks like anticipating any holes in your documentation. Especially if you have a supervisor, send an explanation via email before they need to sign the document. Perhaps it’s a new goal you’ve added to a plan of care that may not be aligned with previous goals. Thinking ahead of your supervisor could prevent a delay and a lot of unnecessary time spent on back-and-forth communication should they need you to clarify something. In this case, you’d be better safe than sorry.

Advantages of Doing All Documentation the Same Way

In most cases in life, routine leaves little room for error. Therapy documentation is no exception. You’re less likely to forget to complete something, or compromise on quality, if you do it the same way every time. Even though every insurance company and state provider has different standards, none of them will have a problem with you being overly thorough with the way you fill things out.

Billing delays also won’t be on you when you’re taking a bit of extra time on the front end to be detail-oriented. As long as your billing is being done the right away, you should get paid faster than you would if you had to make corrections or took too long to sign documents. When you maintain continuity of care for each patient, your claims are more likely to be submitted and paid on time.

Trust us…you’ll also be your clinic owner/admin/supervisor’s best friend if you follow our advice! Or at the very least, you’ll build a solid relationship because they know you’re trustworthy and care about the details. Systemizing on your part, at the patient touch point, makes everyone else’s job easier.

How Using TheraPlan Can Help Standardize Therapy Documentation

We believe so strongly in completing documentation in an orderly fashion that we built easy, organized templates into our web-based EMR. Not only can you complete a treatment note in under five minutes* with our application, but it’ll be difficult to make mistakes because you can see what you filled in last time! TheraPlan is here to support systems for therapists like you because we know how hectic your job can be! Check out all the features of our EMR here.

Like our advice? Share this post with fellow therapists who need a bit of organizational inspiration.

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*After approximately three weeks of training inside TheraPlan, our average therapist completes a treatment note in five minutes or less.


6 Hidden Benefits of Using a Web-Based EMR

6 Hidden Benefits of Using a Web-Based EMR

At TheraPlan, we believe in building electronic solutions for every therapy clinic’s needs. One of the primary ways to take your clinic from disorganization to efficiency is to use an EMR. More specifically, a web-based EMR is ideal for many reasons. Getting away from paper-based records in general is a smart idea in our opinion, but we know that not all EMRs are created equal.

You may already realize the more obvious arguments for accessing your documentation, schedule, payroll, and more from any device via a web browser. It can be incredibly convenient, more secure than facility-based storage, and simple to communicate with colleagues. 

However, there are also unexpected advantages to adopting a web-based system over server-based software. Our team has compiled six benefits you may not have thought of: 

  1. Implementation costs can be significantly reduced. Instead of having to worry about upgrading your computers and network or installing an on-site server, you can transition to a web-based EMR quickly and at relatively low cost. As long as you and your team have browsers and a secure internet connection, you’ll be able to onboard to electronic records without much hassle. This is especially advantageous for any home-based therapists, since they won’t have to carry around any new hardware when they’re out in the field.
  2. The ability to pull reports for billing saves you and your admin team time. Most EMRs have report functionality, and having reports accessible online for billing purposes can drastically increase efficiency in your therapy practice. If you take care of billing in-house, your staff will be able to simply log in to your EMR from any device and pull updated reports or export new ones whenever necessary. Billing agencies, like our partner company, also love the convenience of web-based records. When they need details about a treatment or evaluation, or even demographic data for a patient, the agency staff won’t need to call your office. You can simply provide them with secure login credentials for your chosen EMR so they can perform this research themselves. Without the wait time required for back-and-forth communication, you’ll likely notice that the average length of time in which your claims are processed or appealed will shorten. 
  3. It’s possible to keep an up-to-date live waiting list as your practice grows. Some EMRs, such as TheraPlan, allow patients to be placed in categories such as inactive, active, or pending. This is much more useful than a paper waiting list, as every person who views your patient list will know the current status of each patient. Not only does this lessen the frustration of remembering to update a physical list, but can facilitate quick communication with patients who inquire about when they’ll be able to schedule an appointment.
  4. Holding your staff accountable is easy with accurate, accessible records available any time, anywhere. When you can track minute-by-minute edits on documents and see time-stamped signatures, there is no question as to who did what and when. Although oversight may not be your favorite task as a clinic owner, it’s sometimes necessary to review a specific record. On a daily basis, you can also use the history feature of a web-based EMR to see how quickly your therapists are completing documentation. Whether you use it to hold staff to company policies or decide when caseloads have reached an overwhelming level, this data is crucial for business growth.
  5. Standardizing technology across your clinic will no longer be an issue. Since backups and updates are taken care of, your providers can simply use whatever hardware they prefer, as long as it allows access to an internet browser. While you can still recommend certain hardware, you could completely avoid the expense of providing it for all your therapists. This is a huge money-saving benefit. 
  6. You’ll receive outside user tutorials and technical support at the click of a button. The best EMRs will predict the problems or confusion users could experience and provide resources to help. Within TheraPlan, video tutorials and PDF guides are found in our Help & Forms section. We also have a help desk manned with technical support specialists five days a week. We believe this reduces the amount of technical questions your admin staff will receive, thus allowing them to spend their time on other important tasks.

TheraPlan is your source for all info relevant to your therapy practice: patients, treatments, credentials, and more from anywhere you want to access it. Sign up for a demo today to experience both the obvious and not-so-obvious benefits of web-based technology in your clinic.

How to Set Up Internal Audit Procedures to Maintain Your Therapy Clinic’s Compliance

Following legal guidelines is an essential part of running any type of business, but is especially crucial in the therapy field. Though therapy clinic regulations may not be as intense as those for traditional medical specialties, maintaining compliance can still be quite complex. In fact, this is one of the most intimidating factors of starting a therapy clinic, and can be the downfall of a fully operational clinic if audit procedures are not in place.

Since our EMR was built specifically to make it easy for users to comply with HIPAA and Florida CMS guidelines, we understand the ins and outs of audit-proofing your clinic’s protocol and documentation.

To begin establishing internal audit procedures, you’ll first need to thoroughly understand the components of compliance as they relate to therapy clinics. These can vary depending upon the mix of insurance coverage amongst your patients (i.e. the portion of Medicaid patients vs. commercial carrier patients you see). However, some components are true across the board. Here are five key ideas to keep in mind:

  1. Medical necessity. This is an element that many in the therapy world omit from the compliance conversation. However, it’s essential that your documentation reflects the honorable nature of any treatment your therapists provide to patients. According to CMS.gov, including a statement asserting that the therapist believes treatment is medically necessary “supports approval” of a Medicaid or Medicare claim. Therefore, if your office treats patients covered by either public health insurance program, we suggest requiring the medical necessity statement on all documentation that leaves your practice. In our 25+ years of experience with medical billing, we’ve discovered the importance of this verification for the efficiency of approvals, payments, and ultimately, for your patients’ continuity of care. That’s why we’ve included medical necessity checkboxes on all our therapy documentation templates.
  2. Signature and documentation requirements. Hand in hand with the above recommendation, CMS requires that all treatment notes and evaluations be completed and signed within 48 hours of the therapy session. This is both to ensure that the therapist hasn’t forgotten what transpired and can accurately document a patient’s progress, but also for the security of the patient’s records. The time frame of completion is difficult to regulate using paper documentation. With an EMR that locks and time stamps each document, though, any audit personnel will have assurance that you have complied with this rule.
  3. HIPAA. As you should already know, HIPAA is perhaps the most important factor in compliance, as it has been federal law since 1996. Especially if your clinic is growing, it’s imperative to create a mandatory HIPAA training protocol for each new hire. Asking them to sign a statement that they understand HIPAA law does not protect you from potential loss in the event of a violation, no matter how unintentional. It’s a heavy responsibility to ensure that your therapists and admin staff fully comprehend the intricacies of HIPAA and how to comply with everyday office procedures. Yet, it’s absolutely worth your time and effort to close any holes in knowledge that could jeopardize your practice altogether.
  4. Coding and billing. Two of the most significant components in compliance involve the way you keep your business afloat: by submitting and getting paid for the therapy treatments you’ve provided. Thorough documentation is fundamental to a smooth billing process, as are precise units of time. Next is accurate coding. If you rely upon your staff to code treatments in-house, it’s wise to make sure that at least two pairs of eyes fall upon each outgoing evaluation or SOAP note. Completing this manually can increase the room for error, however. When you use TheraPlan, it’s easy for each user to see which CPT codes they’ve filled in on the patient’s most recent document and use a pre-filled dropdown to select the correct code for their specialty. Whether you complete billing yourself or outsource it to an experienced agency, honest and timely billing processes also fall under the umbrella of compliance. 
  5. Miscellaneous administrative factors. These include secure communication with patients, confidentiality, and fair hiring practices. The details may vary based on your practice size and the number of staff you have available to help, but prioritizing organization in all facets of your clinic operations is a good place to start.

If you’ve integrated all of the above factors into your clinic’s procedures, the next step is being able to prove it. In the event of an audit, you’ll most likely be questioned about your protocol for communicating and maintaining compliance in your clinic. Keeping a record of the way you and your staff address each and every requirement can seem overwhelming, but it’s simply a matter of creating a system. Much like you have created a system for payroll, accounting, and other elements of business ownership, this is truly no different. 

As a tech company, we believe in electronic management of internal compliance efforts. Whether you use shared online spreadsheets that track each person’s access and changes or an EMR like TheraPlan, which automatically records each user’s actions within the software, you should find a method you’re comfortable with to track every person who has interacted with documentation and patient records. That way, there’s no doubt as to what has happened in the event of an audit or alleged HIPAA violation. 

Ultimately, compliance is about integrity. Keeping in mind what’s fair and required for all parties, regardless of the amount of effort involved, will protect you in the event of an audit.

Check out TheraPlan’s security-focused software to discover the ways our EMR can simplify this process for you and your staff. 

*Disclaimer: We do not recommend using this blog as your only source of information regarding compliance. Please thoroughly research the regulations that apply to your state and range of specialties prior to preparing your clinic for future audits.

Theraplan note

Therapist Life: The Importance of Keeping an Open Line of Communication with Your Clinic’s Admin Team

When you got your first job as a therapist, you may have realized there’s a lot more to the role than just seeing patients. Sure, your impact on those in need of therapy may be the most important part, but there are lots of other moving pieces that make a clinic run well. A lot of that depends on you! From completing documentation thoroughly and on time to managing a packed schedule, you do much more than interact with patients.

In our opinion, the most critical element of efficiency in a therapy clinic is communication: between therapists and patients, but more importantly, between therapists and administrative staff. Your position in this communication equation is critical. At TheraPlan, we’re all about making your job easy and efficient. Having watched clinics of all sizes deal with internal confusion and conflict over the years, we’ve come up with a few suggestions to avoid such roadblocks. 

We highly recommend you build a solid relationship with your clinic’s admin staff, whether you work in the clinic every day or you’re a home-based therapist who just calls in for specific requests now and then. Here are a few reminders about the significance of the professional connection you have with your admins:

  • Admins are often the ones who follow up on billing claims and ensuring that you get paid! Your income is dependent upon the speed and accuracy with which claims are submitted and tracked. If admins are responsible for this, you’ll want to ensure that you keep an open line of communication with them and do your part to make this as easy as possible for them. 
  • They can act as patient liaisons for important tasks like scheduling. Seemingly simple tasks, like getting patients to confirm or commit to appointment times, can feel the most overwhelming. If your week is packed and you can’t seem to find time to reach out to patients you need to hear from, why not enlist the help of your admin team? Depending on your clinic’s protocol for scheduling, this could be a great way to ease your daily workload.
  • In order for all of the above to be possible, you should set the tone for communication early on. We suggest doing this in the following ways:
    • Answer emails and provide them with anything they request (i.e. credentialing requirements) ASAP. Remember: admins are the link between you and your clinic owner! Having a ‘paper trail’ is important if you ever encounter a miscommunication.
    • Give them plenty of notice when you need a favor. Your front desk staff is likely swamped, so it may be unreasonable to expect they can provide a quick turnaround.
    • Ask questions so as not to appear demanding. Everyone likes to feel they are being helpful. So presenting your needs as a question can be a great tool. For example, saying “I’m having trouble verifying this patient’s insurance. Would you be able to help me?” is better than “I need you to verify this patient’s insurance for me.” If you don’t know your admins on a personal level, this is all the more important. 
    • Use TheraPlan’s message center for quick communication about patient arrivals, rescheduled appointments, paperwork needs, and more. We believe in straightforward and simple communication so much that we built it into our EMR. Instead of having to send internal email for every little thing, you can stay inside our application and just shoot a message to a fellow user. They’ll get a notification no matter where they are working inside TheraPlan, or upon logging in the next time.

Every professional environment can benefit from conscientious communication, but especially a therapy clinic. Due to the nature of your work, it’s possible to go days without seeing your colleagues face-to-face or spending significant time with them. Being proactive using the above tips can help set a precedent for other therapists and show your admin team that you appreciate all they do to make your job possible. 

Think your peers could benefit from our advice? Share this post on Facebook.

 

7 Ways to Improve Your Therapy Clinic's Communication with Primary Care Providers

7 Ways to Improve Your Therapy Clinic’s Communication with Primary Care Providers

It may be the most frustrating, but also the most necessary, job your therapy clinic is responsible for: communicating with your patients’ primary care providers (PCPs). Relying on another office (that may not run as efficiently as yours) to return crucial documents on time is just not fun. We get it! When a PCP doesn’t sign a patient’s plan of care (POC) within the given window, or their admin staff simply doesn’t get it back to you on time, it can be a detriment to your patient’s continuity of care and your billing process (and not in a good way).

Hope is not lost, however. Instead of simply accepting the resulting inefficiencies as the way it has to be forever, consider that there are some things you can do to smooth the communication on your end. Following are seven essential tips for making your most dreaded communication-related tasks a lot simpler: 

  • Keep good records so you don’t have to go searching for anything. We suggest electronic ones, of course. No matter who is digging for information – whether it’s you as the owner, one of your office admins, or a therapist – there should be one reliable place they can all look for crucial data. This can be achieved with paper files, but only until someone accidentally misplaces that all-important intake form or proof of insurance. That won’t happen when you store critical info in an EMR.
  • Train your therapists to complete documentation on time. As you know, failing to have an evaluation/POC signed by a doctor in a reasonable amount of time can lead to putting patients on hold. This negatively impacts insurance claim processing time, which means you and your therapists are waiting even longer than you already do to receive payment! A good way to reduce this risk is to require that therapists complete all documents within 48 hours after treatment, ensuring that your clinic won’t be responsible for any delays in processing paperwork. TheraPlan’s dashboard Open Encounters tile can make this easy. Any unfinished treatment notes or evaluations will be immediately visible upon logging in, so there’s no way therapists will forget about them. 
  • Get ahead of reevaluation deadlines. In addition to finishing and submitting reevaluation documentation to the PCP on time, it’s a good idea to have therapists complete them as early as possible. We suggest 30 days in advance of the previous plan of care’s expiration. That way, there’s no pressure if PCPs take a bit too long to be signed and sent back. More importantly, there won’t be even a short period of time in which a patient can’t be treated due to a pending plan of care (POC). 
  • Keep all intake forms and doctor’s contact info in the patient’s chart. We cannot stress enough the importance of creating systems for maintaining centralized records in your clinic. It’s critical that every person who will come in contact with patient charts understands the protocol you have established. Whether you have a large office or no clinic and only home-based therapists, keeping documents in one place is possible and easy with a web-based EMR.
  • Set up email encryption and connect your email client to TheraPlan. Secure, HIPAA-compliant communication is non-negotiable in the therapy industry. Yet, trying to monitor this as a clinic owner can become stressful and risky. We recommend that all our clinic owners set up a HIPAA-compliant email service of their choice, then simply connect the email client to TheraPlan in order to send patients records safely and conveniently with the click of a button from inside our EMR.
  • Use TheraPlan’s new TheraFax feature. Send documents to a doctor’s office or insurance company right from your EMR, and receive their replies from within our software. We anticipate that this integrated faxing service will double your clinic’s efficiency when it comes to sending POCs to all of the PCPs with whom your clinic needs to communicate.
  • Network with the doctors in your community. A personal connection can go a long way. When a PCP or their admin staff recognize the name of a clinic on an incoming fax or email, they will be likely to prioritize it. Not only will networking increase your referrals, but you’ll find that communication is much more comfortable if you know the doctor personally, especially when you need to call their office with a concern or request.

There are quite a few steps you can take to improve your clinic’s administrative efficiency regarding communication with primary care providers. The best side effect of paying attention to the above advice is less stress for you! 

This issue is such a priority for us that we built it into our software. Try sending your emails and faxes directly from TheraPlan and see for yourself what a difference this makes for your clinic. Click here to speak to our team about adding TheraFax to your account.

Why Efficient Credentialing is Essential to Your Therapy Clinic’s Revenue

As a therapy clinic owner, you are no stranger to administrative tasks. However, there is a hierarchy of need when it comes to these responsibilities. Some tasks, such as scheduling, can be quite easy to hand over to an admin team or manage with the help of an EMR like TheraPlan, while others are a bit more sensitive. We would argue that one of the most critical things you apply your time and attention to at your clinic is keeping up with credentialing for your therapists. 

Becoming credentialed with an insurance provider is no small feat. Whether you are dealing with Medicare, Medicaid, or any commercial carrier, the process often involves spending hours on the phone (during your precious work day) and even more hours gathering the necessary paperwork. Long story short, credentialing for the rolling list of therapists on your payroll can become quite the nightmare.

While therapists are technically responsible for their own credentials, it’s no secret that they rely on clinic owners like you to keep up with the necessary steps. After all, knowingly submitting claims without credentials can backfire on your entire operation, not just on the individual therapist. If your therapists are providing services to patients and billing an insurance company with whom they are not properly credentialed, there will eventually be consequences, not the least of which is your potential loss of revenue! 

In order to keep cash flowing and allow for no break in therapy for your patients, it’s wise to create an organized plan and adhere to consistent guidelines when it comes to credentialing.

Here are a few things the TheraPlan team suggests for making your credentials record-keeping process more efficient:

  • Communicate openly with new hires. Creating transparency with any new therapists who join your team is essential to maintaining their credentials. Encourage new hires to be up-front about their current standing with each insurance, and ask for demographic data (such as social security number and NPI) right away to avoid any delay when it comes time to renew credentials. It’s a good idea to create a comprehensive calendar for all of your therapists that shows any upcoming expirations in one place.
  • Because each insurance credential differently, take notes on the specifics of each in a central location accessible to future admin staff. In each therapist’s file, be sure to note the date and time of every phone call or other interaction you’ve had with insurances and ask for the name of every representative.
  • Build a monthly process that makes sense for your clinic. If there are other tasks you complete on a regular basis, schedule the credentialing tasks in advance to the best of your ability. Rather than trying to fit it in when you have ‘free time’ and finding yourself stressed by deadlines or facing delays in billing, make applying for and maintaining credentials a top priority. For example, if you always complete payroll at a particular time of the week or month, build in some tasks related to credentialing so it doesn’t build up into a more daunting job.

Even after implementing these efficiencies, the paper trail will inevitably become too much to manage. That’s why we created a specific web-based place for these types of important records to live. Inside TheraPlan’s User Maintenance section, which is accessible to clinic owners and admin staff, there is an accordion labeled Credentials. Here, you can store all the essential demographic data you’ll need to refer to for each employee. Find out more about the administrative benefits of using our EMR here.

The benefits of maximizing efficiency and staying up to date with credentialing requirements are many. If you’re dedicated to keeping up with this building block of therapy clinic administration, you can minimize therapist turnover and create a solid, long-term relationship with your qualified staff. Your business revenue won’t suffer due to missing documentation. Perhaps most importantly, the community of patients you serve won’t experience any gaps in care.

Amending Medical Documentation

Amending Medical Documentation: What’s appropriate?

Your medical documentation serves as the backbone to your practice – authorizations, payments and the integrity of your practice all rely on the accuracy and quality of your medical documentation. With any practice it’s important to stress to all providers to ensure their medical documentation is done right from the start, but it’s also important to establish best guidelines to amending medical documentation after the fact.

It’s important to note that all amendments should be done when the therapist still has total recall of the visit. Industry practice generally says this is within about 48 hours. There are three types of additions to medical records – late entry, addendum and correction.

Late entries are done when you need to add information that was omitted from the original entry. You must add late entries, label them as such, and sign the late entry with your name and date it on the day you added the late entry. Late entries should only be done by the person who treated the patient as they are the only person with total recall of that visit. An example of a late entry may be “It was noted that the patient was lethargic during the visit. John Smith 06/13/2019.”

Addendums are done when a provider wants to attach a note or comment to the medical record that was not available at the time of a visit. For example a speech therapist may have a visit with a child. During that visit they indicate the child doesn’t seem to be hearing appropriately and should visit the pediatrician as soon as possible to check for fluid build-up in the ear. The next day the patient reports that the pediatrician did find an ear infection. The therapist could then add an addendum indicating “Patient saw pediatrician and did report an ear infection and fluid build-up. John Smith 06/13/2019”

Corrections are done for true errors made in the medical record that the provider wants to correct. Corrections should nevercompletely remove what was there before. It should be very clear what the original text was – so just use a strike-through over the inaccurate information. A correction should indicate the current date (date correction was made), time, reason for the change and the initials of the person making a correction. A correction would be done if the therapist loaded a note with a wrong date of service or perhaps indicated the wrong age for the patient.

Lastly, insurance companies may refuse to consider addendums in an audit. For example – if medical records are requested and sent and something is denied because of it – it is not appropriate to add it and try to send in the records again. Because of policies like these it is very important that your medical records are accurate and complete from the start. Addendums and corrections serve their purpose but they should not be a crutch and should be few and far between.  

Why You Should Manage Reevaluation Dates in Your Therapy Clinic

Have you ever had to put a patient on hold because their plan of care expired?

Some clinics can face the dilemma of having multiple patients on hold at the same time. As you know, when this happens, you AND your therapists are not getting paid. Thus, there is quite a strong incentive for training your therapists to pay close attention to re-evaluation dates and completing documentation in a timely manner.

The way to prevent this predicament is straightforward and can truly tighten up your administrative processes as well.
  1. Here is how smooth re-evaluation management can look:
  2. A therapist completes a re-evaluation between 150 and 157 days after the old plan of care began (when there are 30 days remaining until the plan of care expires).
  3. The therapist writes up the evaluation right away and submits to clinic administration.
  4. Your admin team sends the completed evaluation and plan of care to the patient’s primary care doctor.
  5. The therapist continues treating the patient during this final 30-day period of the plan of care, using the old goals.
  6. Once the signed plan of care is received from the PCP, your admin team submits it to the patient’s insurance plan for authorization. Ideally, there is still at least one week left on the old plan of care!
  7. Your clinic receives approval from the insurance/Medicaid plan for the new plan of care.
  8. The patient’s new plan of care begins the day after the old plan of care ends, so there is no down time. This patient never needs to be put on hold and receives continuity of care.
When your clinic uses TheraPlan, the re-evaluation and plan of care renewal process becomes hassle-free. Our application automatically calculates a re-evaluation due date of 150 days from the previous evaluation, which gives your providers ample time to complete their evaluation and go through the administrative process for continuity of care of your patients.

Schedule a demo to find out how TheraPlan can help with your clinic’s specific needs surrounding reevaluations and authorizations.