Counseling (mental health) treatment plan; rational, tips and how to document treatment plan to help with insurance audits will be covered in this blog. If you have ever had an ongoing relationship with a client, you likely have created a treatment plan. Counseling treatment plans serve a valuable purpose: they help both clients and practitioners understand the course of treatment. Let’s take a closer look at the features of these important documents.
What is a Counseling (Mental Health) Treatment Plan?
A counseling treatment plan is a road map for a client’s treatment. Just by looking at one, you should be able to tell why the client is there, what are their past issues, and how the clinician is proposing to treat them. Although treatment plans may vary according to the practitioner, almost all of them contain the following components:
1) Background Information, including psychological history and demographics
2) An assessment of the current mental health problem
3) Treatment goals
4) Treatment objectives
5) Proposed Interventions and a timeline for each
6) An area for tracking progress
7) Diagnostic codes
8) CPT codes- here is the list of the most common CPT codes in mental health
Why Do We Need Counseling Treatment Plans?
The aim of a counseling (mental health) treatment plan is twofold:
1) Present a guide for a client to reach their goals. A client should be involved with their treatment plan. They need to be aware of their goals and objectives and the expected timeline of their progress. This lets them know what they are working on and what they need to do to get there.
2) Assist clinicians in staying on track. Therapy and consultation can go off the rails if you don’t have a clear direction. Counseling treatment plans keep the practitioners focused on the endgame. They provide a structure that is necessary for therapists and their clients. Additionally, they help the therapist monitor client progress and make adjustments when necessary.
Counseling Treatment Plan Checklist
Ask yourself the following questions to make sure you are creating a comprehensive treatment plan:
• Are you getting a complete picture of the client? Assessment of problems needs to encompass all areas of life, including physical/medical condition, relationships, family, legal status, occupation, and psychological history.
• Which problems are most important to address? List them in order of priority.
• Is there a clinical diagnosis?
Goals and Objectives
• Do the goals address the problems listed?
• Does the client understand and agree with the goals?
• Do the objectives reflect the goals?
• Are the objectives measurable?
• Does the intervention fit the objective?
• Does the client understand how the intervention will help them reach their goals?
• Are the interventions time-limited (i.e., have you set a deadline)?
• How will you measure progress?
• How often will you assess progress?
• Does your client understand how you assess progress and when it will occur?
How A Counseling Treatment Plan Can Help With an Insurance Audit?
You may not think insurance and treatment plans are related but a good plan can help you get through an audit unscathed and/or prevent you from getting audited in the first place.
How It Prevents Audits
An individual clinician or institution gets audited when an insurance company feels there may be irregularities in billing. Insurance companies need to see that the treatment they are paying for is necessitated by the client’s problems. A counseling treatment plan helps counselors identify those problems and assign accompanying client objectives. As long as the billing reflects those goals and objectives, it is much less likely a practitioner will be audited.
How it May Save You If You Are Audited
If you are unlucky enough to get audited, a counseling treatment plan can save you from serious negative consequences. It presents a clear guide for the insurance company to follow exactly what you are doing to treat the client successfully. Think of it is as evidence that you are doing what you are supposed to do. Of course, if your billing practices do not match your treatment plan you may be in trouble.
Mental Health Treatment Plan Tips
Let’s look at a few tips to help you through the planning process:
• Just as your billing needs to match your treatment plan, your progress notes need to reflect the goals and objectives you created with the client. Looking at the treatment plan regularly will help keep you focused on the client’s goals during the session. Your progress notes should match those objectives.
• Not only do goals need to be measurable, but they also need to be attainable. It is great to reach for the stars but if a client cannot realistically meet their goals they will likely become frustrated and drop out of treatment.
• Set goals that motivate the client. If the patient is not invested they won’t take the actions necessary to address their objectives. Goals can’t just be important to the clinician. This is their plan, not yours. They need to be highly involved to be successful.
• Make mostly short term-goals but don’t forget about a possible long-term goal. Short-term success will help the client stay motivated in treatment but not everything can be addressed immediately. They may not be the priority, but listing them as a future goal will help everyone keep them in mind.
• Not every client has a clinically serious problem. For example, someone with a few depressive symptoms may not qualify for major depressive disorder or persistent depression. An insurance company may not cover certain diagnoses, especially if they consider them less serious. Don’t lie just to get your client covered. That is fraud and may have severe consequences.
• Don’t make more than four goals at a time. It is simply too much. Three goals are ideal for a treatment plan. A client can’t be expected to focus on too many goals at once. You can keep a few extra goals in reserve for when the client completes the original ones.
• Set a date of completion for your goals. Having a deadline helps keep the client focused. At the deadline, you can reassess the need for the goal. Keep in mind, just because you make a deadline does not mean you can’t continue it as a goal if it has not been completed.
• Be very open with your client about how you will measure progress. Make sure it is measurable and they understand how it works. Plus, telling them about progress checkpoints will keep them motivated.
Mental Health Treatment Plan Templates
Templates for documenting counseling or mental health treatment plan vary from practice to practice but most of them include background information, findings, goals, and objectives. When creating a template for your practice you have two options. You can create one in the Word document and save it on your computer, or you can sign up for an EHR/practice management software that has built in templates. Documenting treatment plan using the software will save you more time and paper and your documents will be stored securely. TheraPlatform, practice management /EHR and telehealth in one, for example offers built in library of counseling treatment plans and one can also edit or build own templates too. TheraPlatform offers a 30 day free trail.