Headway-initiated billing and documentation reviews

The Headway team occasionally conducts a due diligence review of selected providers on the Headway network to help ensure that billing and coding standards are being met. This means that the Headway team will independently review session documentation.

We conduct these reviews to help protect our providers in the event of an audit from a payer and to help ensure that sessions are being billed and supported appropriately by the session documentation.

If you, as the provider, keep documentation separate from Headway, we will request that you send your documentation within 3 business days to comply with this review.

When the review is concluded, you’ll receive feedback in the form of an email outlining our findings and recommendations, or we may request that you meet with a member of the Clinical Team to discuss the results of the review further.

What Headway-initiated billing and documentation reviews look for 

Session accuracy

Every session’s occurrence is supported by appropriate, accurate documentation consistent with best practices, payer guidelines, and applicable licensing and regulatory requirements. Sessions must be billed for the correct date of service listed on the documentation. You can reference our policy for this issue at any time.

We pay special attention to the following factors that support a session occurred:

• The documentation is signed by the provider with the appropriate credentials, and the “signed at date” is within 72 hours of the date of service
• The date and time of the session on the Sigmund Calendar must match the date and time of the service listed on the documentation
  • A session should not be billed for a day on which no encounter has occurred
• The session does not overlap substantially with another session on the provider’s Sigmund calendar
• The documentation for the session appears to be objectively unique to that client’s particular encounter
• The frequency of encounters billed matches the proposed frequency in the documentation (typically in the “plan” section)
  • Every piece of documentation, but especially documentation for sessions held more frequently or for longer than the typical course of care for each modality, should clearly demonstrate medical necessity in the documentation
    
    

Provider accuracy

Headway does not currently support Incident-To billing, which is when auxiliary personnel, such as students and interns, bill for services under a separately-credentialed provider’s NPI.

Our expectation is that all sessions confirmed through a provider’s calendar are for care rendered by that provider.

Evidence-based practice

Every session billed to insurance at Headway must employ an evidence-based practice appropriate to the treatment of behavioral health disorders and appropriate to the selected CPT code.

The following modality examples are not allowed at Headway:

• “SMS Texting-based” sessions on days in which the client and provider made no synchronous contact
• Some wellness modalities such as massage, or cosmetic treatments

Evidence-Based services we would expect to see at Headway include CBT, DBT, Medication Management, and other related services.

Proper coding

The CPT and Diagnosis codes billed through the Sigmund Calendar must be fully supported by the documentation. You can reference our coding policy at any time.

All timed codes must be supported by the time spent with the client in the documentation.

For example: CPT code 90837 requires that the actual time spent providing psychotherapy is 53+ minutes. If the client arrives late or leaves early, such that 52 minutes or less of care was delivered, 90837 cannot be billed.

If you are using the Headway templates, you can use the “start and stop time” to delineate the minutes of psychotherapy provided. If you are uploading documentation, the exact number of minutes spent providing psychotherapy should be written within your note.

For Prescribers, Evaluation and Management codes must be supported by either Time or Medical Decision Making level, as appropriate.

Documentation

All session documentation must meet minimum documentation requirements.

Headway’s Compliance Guide is designed to assist with documentation compliance. You can also reference Headway’s documentation policy.

Examples of elements of proper documentation include, but are not limited to:

• Relevant information for diagnosis, support for diagnosis, and treatment
• Safety Assessment
• Goals of Treatment
• Person-centered detail (e.g. client quotes/description of behavior)

Who views the records 

A dedicated, specialized team of medical coding specialists at Headway will review your documentation, under the guidance and direction of the Clinical Leadership Team. In certain instances, a member of the Clinical Leadership Team may also view the record.

Headway team members receive specialized training on HIPAA, the importance of PHI safety, and the “minimum necessary” rule. Headway also proactively maintains an audit log of all access to client records.

Headway limits requests, use, and disclosure of protected health information (PHI) to what is minimally necessary to accomplish the intended purpose of the appropriate request, use, or disclosure. An example of this is if a chart review is required for the purposes of processing insurance or ensuring compliance.

If you have further questions or suspect any misuse, please contact us.

Authorization to release records under HIPAA

Release of records to Headway and to health plans does not require additional patient authorization because they are considered covered entities under HIPAA.

Additional patient authorization or notification is not required for covered entities, per the “Permitted Uses and Disclosures” section of HIPAA.

HIPAA permits covered entities to disclose PHI when it is used specifically for treatment, payment, and healthcare operations (TPO). Any progress notes shared with Headway or stored on the Headway platform are fully HIPAA compliant. We’ve built a secure infrastructure and platform, maintain SOC 2* and HIPAA compliance, and follow industry best practices regarding cloud infrastructure and encryption. 

Headway team members receive specialized training on HIPAA, the importance of PHI safety, and the “minimum necessary” rule. Headway also proactively maintains an audit log of all access to client records. A dedicated, specialized team at Headway will review your charts on occasion, but only for the purposes of processing insurance, ensuring compliance, and performing other payment and healthcare operations functions. 

If you don't pass the review 

The purpose of these reviews is to promote compliance with billing and documentation standards.

In general, if we locate an area for improvement that does not affect the cost of a claim, a provider can expect to receive an email with feedback at the conclusion of the review. It is our expectation in those cases that the provider amends their practices to incorporate the feedback going forward and that the provider will pass subsequent reviews for the identified issue.

An example of a behavior that may warrant a feedback email would be a lack of support for diagnosis in session documentation.

In cases where documentation behavior continues across multiple reviews, or inadequate documentation affects the cost of a claim, we may ask that a provider meets with our Clinical Team. Additionally, the provider may be placed on a Curative Action Plan (CAP). CAPs allow Headway and the provider to work together to fix the root cause of an issue. The CAP may include clauses that require the provider to engage in remedial training, keep documentation on the platform for a specified amount of time in order to allow further random review, attend meetings with the Clinical Team, and other similar requirements.

• Examples of documentation behaviors that may result in a Curative Action Plan:
  • “Upcoding” sessions (billing more expensive CPT codes than are supported by documentation)
  • Misrepresenting services: for example, billing family therapy as individual therapy
  • Not meeting documentation requirements after receiving a warning about documentation quality in a previous review.
  • Lack of communication with Headway during the review— for example, not sending notes upon request.

Except in very limited circumstances (e.g., suspected fraud or harm to clients), providers are permitted to “cure” any such breaches of their agreements and payer obligations, by remediating or correcting the underlying issue.

If a root cause analysis shows that the source of the problem was a reckless disregard of Headway policies or applicable laws and regulations or willful misconduct, the remediation action(s) may include, but are not limited to, provider agreement termination, withholding payment, clawback of previously distributed payments, civil penalties, or report to appropriate licensing board.

How Headway handles clawbacks as a result of these reviews 

Headway is contractually obligated to correct any overpayments from the payer or the client found during the review. The Headway team corrects these overpayments in respect to the client, and the Plan to ensure that both have paid correctly.

That said, we view alteration in provider payout as a last resort. In the rare event that we have to adjust a provider's payment, our team will discuss the possibility with you beforehand.

FAQ

Are these reviews optional?

No. Compliance with Headway-initiated requests for records, as well as record requests arising from Health Plans is not optional, in accordance with Section V.A. of the Provider Agreement.

It is our expectation that you will comply with a request for records within 3 business days if you are actively seeing clients and/or actively submitting sessions. We also expect that you will meet with our Clinical Team within two weeks if Headway requests a virtual meeting with you.

For more information, review our Provider Communication policy.