Mental Health Practice Information/Preparing for an Audit

Preparing for an audit is a critical and ongoing process for mental health practices to ensure compliance, protect revenue and maintain a high standard of care. Audits, whether internal or external, can be initiated by state and federal regulators (like those for Medicare and Medicaid) or by private insurance companies. Here are key practices for mental health organizations to prepare for an audit:

Organize Administrative Records. Ensure these are up-to-date:
Business license and insurance. Policies and procedures manual.
Emergency protocols. Client complaint and incident reporting logs.

Documentation is often the core focus.
Progress notes: Ensure they are timely, legible, and clinically justified.
Treatment plans: Should be individualized, updated regularly, and reflect measurable goals.
Intake forms and assessments: Must be complete and signed.

Consent forms: Ensure signed informed consent, HIPAA authorizations, and any telehealth-specific consents are current. Comprehensive Client Records: Ensure every client’s record is accurate, legible and complete. This includes full name, date of birth, contact information and demographics; signed consent forms for treatment, release of information and telehealth services; complete bio-psychosocial evaluation or initial assessment; documentation of client rights and privacy practices (HIPAA). Regularly review and update treatment plans to reflect the client’s progress and changing needs. Progress notes must be detailed enough to stand alone providing a clear picture of the session’s content.

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