Name: Medical Necessity Is Being Tested. Is Your Documentation Ready?
Uploaded: 2026-02-19T18:46:11.114Z
Duration: 30 min 28 s
Description: Medical Necessity Is Being Tested. Is Your Documentation Ready?

Transcript for "Medical Necessity Is Being Tested. Is Your Documentation Ready?": How's it going everyone? Welcome to today's webinar with Brellium and Sarah Powell, and we'll be covering some medical necessity documentation review here. I just wanna give a couple minutes to let some people hop in, and then we'll get started. And as we continue along throughout the webinar, feel free to pop any questions or comments in the chat, and we'll be happy to answer them at the end. We have a dedicated QA section from the audience to go over. And people are starting to trickle in. So we're gonna get started here. And, again, feel free to ask any questions in the chat, and, happy to have you all. But to introduce myself, I really appreciate you guys joining. I'm Aidan from Brelium, and we're here to talk about something that's on a lot of providers' minds right now, and it's medical necessity documentation and how to make sure it holds up when funders come calling. And we're joined by Sarah Powell, ABA business consultant and founder of Blueprint ABA Consulting. Sarah's a great partner of ours, and she works with ABA practices across the country on compliance, operations, and clinical quality. So she sees what's happening in the field and what's actually working when practices face audits. Today, we're going to walk through what funders are actually looking for in their reviews, the most common documentation gaps Sarah sees, and what you can do right now to strengthen your medical necessity narratives. We've got about twenty five minutes for conversation. We'll save a bit at the end for your questions. So I would love to dive in. Sarah, if you want to take thirty seconds, introduce yourself, and then we can jump into the questions. Sounds good. Thank you so much, Aidan. I'm super excited to be here talking to you guys today about this super important topic. I've been in the field for over ten years, been a a BCBA for over ten years as well and recently started consulting. I do a lot of consulting work with large organizations, small organizations, but my passion really lies in clinical quality, auditing, compliance. So I'm really excited to be here today to share with you guys all of my expertise and my knowledge and the things I'm seeing in the field, right now. So thanks for having me. Yeah. Yeah. Of course. That's great to hear. And just to kinda start off here, we'd love to hear from you on what you're seeing in the ABA compliance landscape right now, and kinda what's changed in the past six to twelve months maybe. What's different now compared to, the past? Yeah. That's a great question. So I think over the last, you know, six to twelve months, I've seen a noticeable increase in scrutiny across the board. Right? Funders are looking much more closely at documentation, especially around measurable progress, treatment intensity, and medical necessity. So what I think has changed is not necessarily the rules. It's the enforcement. Right? So I'm seeing much more frequent audits. I'm looking at, more requests for records, whether it's prepayment or post payment, requests for records. Seeing more partial denials, right, due to talk documentation gaps. We're looking at, Mhmm. a much larger, like, emphasis on on data trends. People wanna see data and the progress that their patients and clients are making. And then lately, a lot of scrutiny on nine seven one five five and nine seven one five six, like those parent training notes. So, yeah, there's also less tolerance for things like vague language. Yeah. So, again, not necessarily rules are changing. It's just more eyes on the document. Yeah. So yeah. A 100%. We've been seeing that as well. And in your experience and with the clients that you work with, is there any specific states that this this is happening in, or is it nationwide? To be honest, it is a nationwide trend. More states, you know, are are seeing like, we have bigger eyes on those states, but it is a nationwide trend. So you know? And there's a few reasons for that. So Yeah. A 100%. And kinda going off that, would love to hear from you when funders audit medical necessity documentation, what are they typically looking for? And if you could walk us through what strong med necessity documentation looks like, and where it could, you know, go wrong or potentially be weak documentation, that would be great, I think, to to cover to start here. Yeah. I I think that to start off with, auditors are they're not just checking for completion of session notes or a treatment plan. Right? They're looking for clinical reasoning. Right? They wanna see a logical chain. They don't wanna just see that this child has autism. Right? They also want you to see they want you to talk about the symptoms of ASD that you're seeing in your clients. From there, they wanna see the functional impact, right, that you're making on this child. So that that ties into the goals that you're creating, the goals you're writing, the goals you're working on during that session. Right? We wanna see measurable targets. You know, I, you know, once spoke to an auditor over the phone. Like, yes, our targets were measurable, but in some instances, they weren't attainable. Right? So an example of that, we had a two year old and one of their targets was, oh, zero instances of tantrums, zero per day for three consecutive months. Well, that is not, you know, an attainable goal for a two year old. A typically developing two. year old has tantrums. Right? So it's so yeah. So, I mean, it's not just measurable goals. It's goals that can actually be attainable. They. wanna see data. They wanna see the data you're taking Mhmm. during your sessions, and they wanna see that intensity justification. Right? If you're requesting forty hours a week of ABA services, they wanna see that justified in the number of targets that you're working on per per session hour. They wanna see the progress that their, clients are making through through ABA services. Yeah. A 100%. A 100%. And I think it would be great to hear from you in terms of we wanna hone in on what are those most common documentation gaps that you see that are gonna trigger those denials, and what payers are looking for moving forward. Yeah. I think, a big thing I see is vagueness. Right? Providers being very vague, using Mhmm. language examples such as, oh, the client was upset. Client made progress. Mhmm. They needed prompting. Right? You really need to elaborate that. If you're going to say that a client was upset in your session anecdote, right, I need to know, okay, what made your client upset? What did upset look like? What did the provider do in response to the client getting upset? And then how did your client respond, right, to. something that you used? So really that store, right, that that story is important in the auditor's eyes. We can't just think you know, we we don't want them to assume anything. We want the story to be very clear. This is what happened. This is what we did. This is how the client responded, and this is where we're going forward from there. The other thing I see quite often, contradicting information. This is huge. Right? Mhmm. Sometimes this is not even, you know, your your staff's fault. Sometimes this is contradictions within the template. Right? We all create templates within our CRM systems, and sometimes they have conflicting information. That's a really easy thing for auditors to red flag. Mhmm. That that's a common thing, and it's very easy to fix. Right? Look at your session note templates. Take a look at what's happening. The thing I see, like, huge documentation gaps is, like, things, I guess it'd be, like, data. Right? If you have a three hour session, I need more than three data points or five data points. Right? The amount of data you're taking should align with the number of hours of your session. We we all know we we've had sessions before where we can't get enough targets. We can't run enough probes. We can't run enough programs. Right? There needs to be a reason why. Maybe there was high rates of behavior. The intensity of behavior was high. Right? So we focused on mostly behavior during that session. Well, that should be clearly. in your session anecdote. Right? Like, we wanna know the barriers that you had during that session that led to maybe lower targets being ran during that three hour session. Yeah. Yeah. Completely understandable there. And I think it would honestly be great. You know, you touched on these gaps here, that we typically see, and, you know, you you it's hard to tell when you're making that documentation what's gonna be good and what's not going to be, perceived well by the payer. And I think it would be great for the providers that are here with us today, when they're reviewing their documentation and wants to strengthen it before, you know, the next authorization, what should they focus on first to address those gaps that you just discussed and make sure that that documentation quality is very strong? Yeah. I think this is huge. I think this is a piece that I really want everyone to to take away from this is that templates matter. Your session note templates matter. Your treatment plan templates matter. At the end of this call, you know, please go look at your templates. Right? You know, I've been involved in implementations of CRM systems. I know that you create and you develop these session note templates when you start implementation. Right? For some of you, that may be a year, two years ago. Well, things change in the insurance world, and maybe you didn't update your session note template. Right? Go back and look at your templates. Make sure that it aligns with all those payer guidelines per your state. You know, I would look at the strictest payer you have and make sure your template aligns with all those requirements that they have. Like, even if your staff is very, very well trained, they know exactly what to write. If the template doesn't have the correct information on it, you know, chances are you're not gonna pass an audit. So take a look at your templates. Again, session note templates and your treatment plan templates. Right? And this will really help avoid any red flags that auditors are looking at. And then from there, templates can can really help you. Right? We know in our CRM since symptoms in our in our CRM, we can put prompts in, right, that the payers don't see, but your staff sees. So I would really hone in on making sure that you're prompting your staff the right way. Tell them exactly what you wanna see in that section so that they're much more likely, you know, to do the sections correctly. And from there, I think train train your staff. It's so important. Right? As BCBAs and clinicians and RBTs and behavior technicians, you know, we're not trained in writing notes that'll pass an insurance audit. Right? We're trained to write notes about the services we provide. And sometimes the services we provide and what insurance requires are not the same, unfortunately. So train your staff. Right? Invest in organization wide trainings. You know, once you are looking at the session notes more under the scope, do individual trainings for some of those providers who just need a little extra help. Right? If you're gonna change your session note templates, I do suggest an organization wide training about what changes you made, why, and what the expectations are for each of those, sections in your templates. Yeah. A 100%. And I think it'd be interesting to hear, you know, what are some warning signs an organization might see that warrants some broader retraining, like you mentioned? Or are there, you know, maybe some template mistakes that you're seeing over and over? Are there, you know, specific things in the documentation that kind of warrant that that training that you mentioned to really hone in on payer guidelines? Yeah. I think the session anecdotes you know, I I review a lot of session notes for companies. Right? And the session anecdotes are always lacking. I would definitely provide training and and not just for behavior technicians, but for supervisors and BCBAs as well. Right? Like, it's very important to know what should be included in that session anecdote, what things to avoid saying, what things you definitely wanna have in there. That is a really, really good training. You know, a lot of templates, we use drop downs and, you know, check boxes, and that's all great. But the session anecdote is a very, very important part of that note. It shows individualization, right, to to the auditor. That's important. Right? Not every single session should look the same. They don't expect it to. That narrative is very, very important. So if you're gonna do, an organization wide training, I suggest it definitely be on how to write a good session anecdote that would hold up, for an audit. Doesn't have to be long. You know what I mean? It just has to include all of the key things that they wanna see, in that narrative. You know, I I am looking at the chat, and some of you mentioned things like copy and pasting. It's a big no no. Like, you don't wanna copy and paste anything. Just like we're using technology, so are they. Right? I'm I'm sure their technology will easy easily catch something that's been copy and pasted or looks exactly the same as a previous note. So those are just little things that, you know, you guys can do now to really help make sure that you're audit ready in case you do get audited. Yeah. That makes a lot of sense. And, you know, I've I've worked extensively with a lot of our customers here, and seeing that session narrative and really honing in on how it's documented is very important. And, you know, one of the things we do check for at Brellium is is the session narrative copy and pasted from a previous session? We know that's a big no no just like you said. Yeah. And I I completely agree in terms of making sure that narrative section is good to go. when you ship out to to payers. Kinda shifting topics here a little bit. Would love to hear from you on how providers should think about document documenting treatment intensity and kind of what justifies the hours being requested. Yeah. That's a great question. You know, I also review treatment plans, you know, on a pretty regular basis. So I see the reports that come in from BCBAs, and I've been on the other end of calls, you know, trying to justify the number of hours, you know, with payers that we're requesting. We don't we don't wanna have to do those calls. We want our treatment plan to speak for itself. If we are requesting forty hours a week, we want our treatment plan to tell the auditor or the reviewer exactly why we need those forty hours. That really starts with documenting medical history. Right? Like, I want you to talk about the autism diagnosis. Want to know what level of ASD they have. I want to know when they were diagnosed, by who they were diagnosed. And then as clinicians, I want to see the right assessments, right? Like I want you to be able to tell the story of why this client needs forty hours, whether that's a Vineland, a Vineland plus a VB MAPP, or a Vineland plus an Ables, or if you have a client that only needs ten hours a week and they have a deficit in their social skills. I wanna see a social skills assessment. Right? Those assessments will really help you justify the number of hours that you're gonna be requesting from from insurance. There we go. Yeah. And then from there, I think it's important you know, I've seen reports. You're requesting thirty hours a week, and there's five goals. Well, that that's not gonna fly. Right? If you're requesting forty hours a week, I need to see that there's enough goals for you to work on in those forty hours a week. So enough goals to support that. Another key thing they wanna see is parent training, parent involvement. Right? They wanna see goals that align with the treatment for their child. They wanna see and they're they're gonna wanna see data as well. Right? That that's very important. Like, when you start writing your parent session notes, parent training notes, you have to pull data in. So just keep that in mind. And then to be honest, if you're gonna be requesting forty hours a week, they wanna know what that transition plan looks like, what that discharge plan looks like. Right? They wanna see, okay, we're going from forty hours a week to thirty five hours a week when these things happen. They should be measurable and, again, attainable. Right? I've been on the phone call, you know, with these reviewers and they're like, you want this trial to be typically developing, but they have autism. Mhmm. That's not going to align. Right? So it's just very to keep those things in mind. You know, having all those things will really help back up your claim of why this client needs that intensity. And and I guess, like, behaviors too. Right? If you're talking about behaviors, I wanna know how intense these behaviors are. Are these safety concerns? Right? So maybe this client is in a level three ASD, but they have some behaviors that are very, very severe. You know, they have safety concerns. Right? Like, elopement issues, things like. that. Well, I need you to be able to tell me that in the treatment plan so that when you request, you know, thirty hours a week for this kid that's maybe only level one, I want they should be able to know why from that treatment plan. Yeah. Totally. Those are those are great points to definitely hone in on when you're talking about that intensity. And, you know, so far in this kind of conversation we've been having, we've talked about what good documentation looks like and how we can kind of fill those gaps that may exist currently, but how do practices actually make sure that every chart is meeting that standard without, you know, potentially burning out their clinical team? To be honest, it's very hard to look through every single session note that comes through. It's almost impossible. Right? So I've seen companies before they get audited. And, you know, when you get audited, sometimes it's for like a whole year worth of services. a. month. You know, it's it's extensive to look through all these all these notes. Right? So some places hire me, and I'm like, I'm not gonna look through thousands of pages. You know? You have to turn this in. Typically, you have thirty days to submit these records. Right? So, you know, I'm I'm only maybe gonna look through 33% of these. Right? And and then what? Right? Like, I'm gonna just, like, speak on Brellium and, like, why I love it. It allows you to be proactive. Right? It allows you to catch things as they happen. And if you can fix it, you do. Right? It'll I just feel like it allows people to feel more secure and not as stressed when they do get an audit. Because, yeah, it's very hard to look through every single session note that happens. Sometimes some clients have. two session notes in a day. Right? Because they Mhmm. different therapists. So, yeah, we need technology to kinda help us make sure that all of our session notes would pass an audit. Can have your BCBAs help do it, but, again, that's work that's not billable and you know? So Yeah. A 100%. And it'd be think I think it'd be great to hear for those in the audience, who aren't super familiar with Brellium on how has working with a tool like Brellium changed your clients' compliance practices, and kinda what does, what does it look like when a provider potentially gets a Brellium audit report, and what can they do with that information, to better serve their organization? Yeah. Great question. So the Brellium platform is super easy to use, and I think that's what makes it so nice. Right? It's very easy to see. It's also very customizable. Right? Like, Brilliant brings you like, from their expertise, their knowledge, these are all the red flags that we've seen. But then they allow you to add red flags that you want to that you wanna catch. Right? From there, they'll start auditing all of your session notes on a daily basis, and you can have whatever team member you have review those. Right? So you can tag things on Brilliant, whether it's like a maybe a a note passes, but it has a critical error. It allows that reviewer to look at that more closely, and then you can send automated emails to the providers directly through Brellium, which gives you a chance to kind of give them information. Like, hey. You're not hitting enough targets per hour, those types of things. Once that provider has that feedback that day, the next day they can start implementing that feedback. Right? And if they don't, Brellium gives you the opportunity to look at all your providers with every single category that you audit, so you can kinda see if they're actually implementing the feedback. One really cool feature is it, like, scores your providers. So you can kinda see which providers are consistently meeting a 100%. Right? So you can give positive feedback to those that are doing really, really great notes, and I think that's really important. I I've worked at organizations where, you know, behavior technicians, RBTs, they don't get feedback on their session notes. So they just assume that it's good. So why would they change their session notes if, you know, they're not giving feedback whether they're good or bad? So Brellium really allows you to kind of, give feedback on a daily basis in a way that's very simple and easy through their automated email system. But not you know, it not only allows you to see it as provider level, it allows you to see how the organization is doing per red flag. So for example, if consistent people are failing the data targets per per hour, you know, only, 50% are. passing. Well, that gives you a good idea. Like, okay. Maybe we need an organization wide training on how many data points need to be taken per hour. Yeah. So I like that it gives you that that information to kind of build trainings and Mhmm. and maybe when organization wide trainings are important versus, you know, very pointed trainings with specific providers. Mhmm. Yeah. A 100%. And that's really our goal, at Prelim is not only to mitigate that compliance risk that typically comes with that manual QA process, but also really give you that visibility, like you said, into your organization to see where the pain points are in your documentation and really iron those out and make sure that you're well run and smoothly documenting so all that risk is eliminated. For sure. You know, we are kind of running up close to time here, so I'd love to open the floor to some questions from the audience. So please feel free to start sending them our way. I'll start here with, one that caught my eye here is more providers are using AI to draft notes. And how can Brellium help make sure that the AI assisted notes are compliant? Yeah. Great question. One of the organizations I just worked with to implement Brellium, we created red flags on the session anecdote. So we told Brellium, I wanna make sure they have this, this, this, and this. Right? So in your in your scenario, if they did use AI to draft these notes, if that failed, right, like, if if they if AI wasn't you know, didn't summarize the note in the exact way you wanted, it would red flag that for you. So I think that that that's a pretty cool way that you can use it because not only does Brellium look for red flags and, like, some billing errors, they can actually, you know, take a look at your session anecdotes and make sure it has all of the important information that needs to be on there to get to get approved. Yeah. 100%. And we we've seen that often. We've done, actually, a report on AI scribes and, you know, documentation there, and I've seen that they honestly make no difference in how compliant your notes actually are. And so it's interesting to see that, you know, obviously, they help clinicians on the front end eliminate that that burden of having to document during the session, but they're not doing much in terms of making sure your organization's compliant and that documentation is correct. Another question here from the audience. Some providers are seeing denials because the patient is too old for ABA, and what data should they include to kinda answer that effectively? Yeah. That's a good question. Is this, like, for a treatment plan and your treatment plan or for session? I I would assume so, but we can. talk about both. You know, I I would pull in they they wanna see data to support this. Right? So what I always tell providers, for example, if you had a client that was receiving thirty hours a week of service and they had a schedule change and now they're only receiving fifteen hours a week, Was there a regression? Did progress slow? If so, then you can come back and say, okay. Look. This client this client, you know, when we reduce services, they regressed, which justifies the need for that intensity. Same thing with, you know, clients that are too old. If you're able to justify with your data that ABA is still effective at the hours that you are working, that should be enough. Have your data justify why this client still needs ABA. The way to do that is by measuring progress. Right? Have the right goals in place. I always look at short term goals that are attainable within that six month authorization period. That way you're mastering things out. You're adding new things. That way, if they say, okay. Well, this client is too old. Well, you can say, well, ABA is still working, and here's the data to prove that. Yeah. A 100%. The data sections are obviously very important there. One, I think, final question, we are coming up on time here, but I think this is a good one to kinda end on is how do we pitch systemic chart review to our finance team, our owners, and what convinces them this is a good investment? It's a question that one we see from a lot of people that we talk to, but a lot of people in the audience are wondering this as well. Yeah. Thank you for asking that. I'm very, very passionate about this question. Right? Investing in a system like this not only shows, you know, your staff members that you are you care about clinical quality. Right? I'm a BCBA. I've been a BCBA for a long time. When companies invest in good clinical quality, that means a lot to me. Right? Good clinical quality like, we're all doing good work in the field. Right? Or at least I hope so. Your documentation should match that. That's how we're gonna continue getting these services funded, continue to, you know, see clients. You know, I I've worked with a company before. They've gotten audited, and they've passed all their audits. And guess what? That insurance company sends clients their way now. Right? So it could help increase revenue. If you have good documentation, payers are gonna recommend you to their clients. Right? Also, I mean, it's it'll hook the money line. Right? If you fail these audits, you will get you will get money recouped, unfortunately. And to be honest, I've seen audits come in from a year ago, two years ago. Right? So this is so important for maybe brand new companies that are just starting out, like, invest in this now because we all know that documentation may not be as strong, you know, back then as it as it is now. It's not to say that they're not gonna audit your notes from a year ago or when you first started, and then they could recoup those funds. That could be really, really devastating to some of these smaller organizations if they claw back $20.30, $40,000. Right? So I think that in itself is the reason why to invest. You have peace of mind knowing that if you do get audited, your notes are sound. And then, also, you're. just clinical quality. So it's not just good on the clinical side, but also on the business side. So I don't think you can go wrong with an investment like this. Yeah. Yeah. It makes a lot of sense there, Sarah. And as we wrap up here today, just you know, we only have a minute left here. I wanna leave everyone with kind of one key takeaway, and that strong documentation isn't about writing more. It's about writing clearly. And auditors aren't looking for, you know, lengthy notes or buzzwords. They're really looking for clinical reasoning and a clear connection between symptoms, you know, functional impact, measurable goals, data trends, treatment intensity, everything that we chatted about today. And when that story is clear, medical necessity becomes obvious. And when it's vague or inconsistent, that's when denials, clawbacks can happen in the future. And, you know, if today's conversation highlighted gaps your team wants to address, you know, spark some interest into looking into Brellium, we'd love to connect. Know, bring yourself, bring your owner, bring your clinical director. We'd love to have a conversation around, some of the work we've been doing with similar organizations and continue that and do some good work in the space. And thank you all for being here. Thank you so much, Sarah, for. joining us today. It's been a great session. Yeah. Thank you guys for having me. Yeah. Thank you. Have a good one, everyone. Bye.