Most insurance carriers and HMOs outline the minimal documentation they require for funding. Some insurers require physician orders for initiation and continuation of treatment, for example, but do not require standardized and formal daily notes or progress note documentation. They may request working papers and notes regarding the services provided. Providers must be able to produce standardized documentation regarding the services provided, and the progress obtained by the child is more likely to receive reimbursement

The development of standardized procedures should be based upon knowledge of both the Medicaid requirements and the provider requirements and procedures. It is important to incorporate both methods in order to minimize paperwork and avoid allocating extra staff time to the completion of documentation. The integration of the two methods can be done within the IFSP process.

Documentation serves the following purposes:

  • It provides a record of the child's condition and the course of treatment from initiation of the IFSP through the time of discharge
  • It serves as an information source for children and their families
  • It facilitates communication among the professionals involved with the child
  • It furnishes data for use in treatment, education, research and funding
  • It provides a method for documenting quality assurance

There are two major components to documentation: the individual child and the service provided and funding for services provided. Child-related documentation includes evaluation reports, IFSPs, daily notes, consultation reports, progress reports and discharge summaries. Third-party access forms include child identification forms, referral authorization, parental consent forms along with insurance information, physician orders, practitioner credentials/license, service logs and tracking forms.

Third Party Access Forms

The family must be given assurances that the provider will correct any adverse financial situations that may arise because of the provider's receipt of insurance proceeds.

The family initially might feel it is subject to an increased financial risk because the provider's efforts might:

  • cause insurance premiums to rise,
  • reduce available lifetime or periodic benefit maximums,
  • result in deductible and coinsurance amounts to be paid by the family

It is not possible to provide absolute protection against an increase in premiums, or even to prove that such an increase would happen solely because an insurance plan paid out benefits on claims for medical services not previously filed.

Most insurance plans have lifetime benefit maximums, but such maximums are rarely ever reached because:

  • the maximum is set at a relatively high amount (for example, $1,000,000);
  • groups switch to insurance carriers that offer new plans, resetting the maximum benefit;
  • ormany plans provide for reinstatement of a portion of the lifetime maximum used in any one fiscal period

A definite contingent liability exists for the provider, and that is associated with the possible exhaustion of periodic benefit maximums. For example, some insurance plans will place a limit on the number of therapy treatments covered in a benefit period, although most plans will limit the number for each illness per period. Thus, a provider might exhaust the available physical therapy benefits, leaving no benefits payable for an unexpected acute episode (for example, a broken arm).

Physician Authorization

In order for a provider to access private insurance plans or HMO/PPO plans, it may be necessary to obtain a physician authorization. The initial authorization for evaluation and/or treatment can be obtained by requesting the physician to sign a form created specifically for this purpose, or it can be obtained by telephone. If permission is obtained by verbal orders, written documentation must still be obtained. To document verbal orders, a telephone order form should be completed and sent to the physician for signature, providing a written record of the date the services were authorized. The physician orders should be maintained in the treatment record.

Physician authorization for treatment can also be obtained by adding a line to the bottom of the evaluation or assessment report and forwarding it to the child's attending physician for signature and dating. Physician reauthorization for continuing intervention can be obtained using the progress summary form or the consultation report.

Providers initiating a third-party billing may not wish to contact physicians by telephone or send IFSP reports without explanation. An authorization form should accompany any communication with the physician.

Participation/Consent Form

Parental consent forms should state the provider's authority to access third-party payer sources and should request parental authorization for access of the family's health insurance. The form includes a statement for the authorization to release information to insurance that is necessary for processing a claim and assigns benefits to the provider.