Third party payers (like insurance companies) don’t want to pay for something services if the services are not being provided.
Insurance companies want to know that the services were being provided.
Documentation is our receipt for services.
If it wasn’t documented then it is considered that it wasn’t done.
Documentation is written proof that services (like group therapy session) occurred.
An example is if a recreation therapist doesn’t document the assessment, treatment plan, and interventions. The insurance company may review documentation (or missing documentation) and request their funds back because they aren’t paying for services that weren’t provided.
Beyond documenting for services:
They want to make sure they’re paying for services that are bringing about specific outcomes for patient’s treatment needs.
They don’t want to pay for something just for the sake of having it. In example: They’re not going to pay for recreation and activities just for the sake of having these services.
These insurance companies are paying for specific treatment outcomes. These outcomes must be measurable.
What if the insurance company wanted their money back because there was no evidence or poof of outcomes.
What to document:
Summary of recreation therapy assessment
Treatment plan: Write measurable patient outcomes. Include: Interventions that are to be provided by rec therapist as part of treatment plan to assist the patient in reaching these outcomes.
Document that intervention was provided (in example: pain management, anger management, endurance building, social skills, etc.) It’s not about the activity. It’s about the outcome. However, a variety of activities can be used to help the patient reach the outcome. It is best if there is research based evidence that the specific activity/ intervention has been proven to bring about outcomes.
Documentation of patient’s progress or lack of progress in the session note.
Document the specific outcomes that occurred.
Things that aren’t to be documented:
Group therapy or intervention notes before they were provided.
What you assume.
Hearsay: in example: avoid documenting, “activity assistant said the client performed well.” Documents on what you observed.