How to create effective, compliant treatment plans for clients with commercial insurance

Think about the last time you visited a doctor for a non-acute medical issue. It’s likely that your provider made an assessment and diagnosis based on your presenting problem, and you left the appointment with a plan — an understanding of your prognosis and recommended next steps for treatment to achieve relief.  For example, say you came home from a camping trip with an angry rash on your legs. When you go in for an exam, the doctor tells you you’re experiencing a case of poison ivy and recommends a prescription steroid cream to treat it. Heading out of the clinic, you know where to pick up your prescription, how you should apply it, and what to do if things don’t improve in the next few days. This simple example demonstrates that treatment planning is a mainstay of medical care. Similarly, treatment planning is a foundational element of effective mental healthcare. But, unlike the physician-authored treatment plans that are typical of medical settings, treatment planning in the mental health sector is a collaborative process. Including clients in the treatment planning process ensures you both have a shared understanding of how treatment will help them and what to expect next. And as is the case with medical treatment plants, mental health treatment plans must be reevaluated and updated from time to time based on the client’s progress and needs. 

What goes into an effective treatment plan? 

Therapists in the Rula network are required to create an individualized treatment plan in collaboration with every client at the beginning of treatment and update it throughout the episode of care as clinically indicated.  Treatment plans should always be co-authored, meaning that they should be done in session with the client and reflect mutual agreement of the plan of care. This is a requirement for every commercial payer contract and is an industry standard of ethical clinical practice. At their core, treatment plans help us answer the questions:

• Where do you want to go?

• How can I help you get there? 

All treatment plans contain two basic components: goals and objectives. Goals are the “big picture” changes that require a series of smaller steps (objectives). All clients at Rula are required to have at least one active treatment goal.  When defining a goal for treatment, a best practice is to identify both a client goal (what they hope to achieve or change as a result of therapy, in their own words) followed by a clinical goal (how mental health treatment will assist the client in reaching that goal). The clinical goal and the client goal are the same but the language we use to describe them differs.  For example, say the client reports that their goal is to “feel less depressed and not be so anxious about leaving the house so I can make more friends.” In this case, the clinical goal might be to “learn strategies for managing social anxiety and navigating low mood, learn tools to increase distress tolerance in social settings.”

How do treatment plans differ when a client pays with insurance?

If you’ve never billed insurance before, you probably have some questions about what it’s like to practice in a commercial payer environment. But rest assured, the core elements of a treatment plan are very similar across the board whether you want to bill Medicaid, Medicare, commercial insurance plans, etc. One important consideration when billing, regardless of insurer, is that medical necessity must be demonstrated in your documentation. In other words, if the treatment plan and progress notes do not clearly reflect a covered diagnosis, symptoms, functional impairments and that clinical interventions were used, insurers may not cover the service or authorize additional care. When this occurs, a client has the option of switching to  “self-pay” and paying out of pocket instead of using their insurance. But for financial reasons, self-pay isn’t always an option for clients. To ensure care is not interrupted for your clients, or you, having an up to date treatment plan and documentation is critical. 

Five best practices for effective treatment planning

1. Tailor the plan to your client’s unique needs. 

Ethical, effective treatment plans must be tailored to each client’s presenting problem, strengths,  and unique goals. Even among several of your clients with the same diagnosis, it’s important to avoid “canned plans” that offer generic goals and objectives, and instead ensure the plan is reflective of each individual client’s unique treatment needs. To accomplish this, be sure to collaborate with your client, and their evolving treatment needs, throughout this process to establish what works best for them.  You might consider saying something like “We are on this journey to reach your treatment goal together, and you are always in the driver seat pointing us to where you wish to go. I am in the passenger seat and together we are going to navigate our way through this by using the treatment plan as our roadmap.” 

2. Let your client’s diagnosis inform the plan. 

Commercial payers expect clients to have a covered diagnosis in order to reimburse for services, and it’s important that the treatment plan reflects that diagnosis, and associated symptoms, as well. In doing so, this helps maintain what is called “the golden loop” where the treatment plan is in direct alignment with the presenting problem, and all other documentation in the record So for example, if the client has Generalized Anxiety Disorder (GAD), commercial payers would expect to see a treatment plan with goals and objectives that are directly addressing the symptoms of GAD, and any associated functional impairments as a result. 

3. Update the plan whenever clinically necessary.

If you’re wondering how often you need to update your treatment plans, the answer is one you’ll probably be familiar with — it is up to your clinical discretion. Most commercial payers don’t have a set cadence for updates.  So it’s up to you to update the treatment plan as often as is clinically indicated or whenever a meaningful change occurs. This could be an uptick in the severity of your client’s symptoms, a lifestyle or environmental shift, or a client meeting an initial objective or goal. As your client’s needs and situation evolve, work together to refresh their treatment plan to make it relevant to whatever is currently happening in and outside of sessions.

4. Include small but measurable targets to build positive momentum. 

In order for treatment plans to support meaningful change, they need to include goals and objectives that are specific, measurable, and appropriate to a given timeframe. This isn’t always an exact process and it might take some trial and error to understand the cadence that works best for your client.  It’s always best to err on the side of achievable to build positive therapeutic momentum. Helping your client achieve some early wins will help them feel like therapy is working and potentially help them achieve symptom relief sooner.

5. Focus on one goal or objective at a time. 

For clients with complex treatment needs, it can be tempting to want to address everything at once. But often, the most effective approach is to simplify. It’s better to have one goal or objective that’s clear and focused and update it frequently (versus having numerous expansive, goals and objectives that can elicit confusion and overwhelm). It can be difficult to make progress on multiple goals at a time. So simplifying the treatment plan, and updating more frequently, can help both therapists and clients stay focused and accountable for how sessions progress.

Meet Rula, your treatment planning partner

Sometimes, even the most dedicated therapists struggle with “documentation dread.” (Same!) And if you’ve never billed insurance before you might be feeling unsure of how to document in a way that meets commercial payer requirements and fits into your practice workflow.  At Rula, we’re here to help take some of that administrative burden off therapists so that you can focus on doing what you do best. Our team can help you understand the specific treatment planning documentation required by commercial payers and simplify the process of going in-network. To learn more about all the ways Rula can support you in treatment planning, billing insurance, and growing your private practice visit our website.