3 CE Credit Hour Presentation on Insurance Documentation
Dealing with Insurance: How Auditors Think and Why
Here’s some good news—insurance documentation doesn’t have to be the part of private practice that keeps you up at night.
Dr. Maelisa McCaffrey presents this updated and expanded course to cut through the confusion around what insurance companies actually want to see in your progress notes.
3 CE credit hours
(1 CE credit hour of which is designated as legal-ethical CE)
Will include houdouts and resources, including:
- Diagnosis justification statements
- Common treatment goals
- Progress statement formula and examples
- Sample progress notes
- Client file review tool
On Demand Self Study
Whether you’ve been practicing for decades or just got credentialed, you’ll walk away with concrete strategies to document with confidence and clarity. We’ll demystify the ever-important concept of medical necessity, explore what auditors are really looking for (and why), and give you practical tools to review your own documentation before anyone else does.
This isn’t your typical lecture-heavy CE course. Expect real clinical examples, sample notes we’ll review together, and plenty of time for your questions—because every practice has its own unique documentation dilemmas. We’ll cover everything from informed consent language that protects both you and your clients, to treatment planning that satisfies insurance requirements without sacrificing clinical judgment, to self-auditing techniques that will actually help you simplify progress notes. You’ll get hands-on practice “auditing” sample files alongside the presenter, learning to spot red flags and understand what makes documentation audit-proof (or audit-prone).
By the end of this interactive session, you’ll have a toolkit of strategies to approach insurance documentation with less stress and more clarity. The presenter brings both expertise and an engaging, down-to-earth teaching style that makes even the driest policy details accessible and—dare we say it—occasionally entertaining. Whether you’re a counselor, clinical social worker, marriage and family therapist, or psychologist, this course will help you move from perpetual worry to genuine confidence in your documentation practices.
Real feedback from the live event:
“Melissa is a stellar presenter and person. The material she prepares for us is brilliant, useful, and adaptable (not to mention thorough). I love the clarity of her mind and way of communicating; just extraordinary. She is trustworthy, i.e. know how to use her presentation tools, and engagingly friendly. Here’s the kicker for me: I actually started getting excited about moving toward excellence in my charting!! She’s inspiring and brings out the best in people. What a gift she is. Thank you for having her as part of what PCT offers; she’s a Super Asset!!!”
“This is probably the best training I’ve ever been to :)”
“Thank you so much for hosting this and Maelissa for all of her wisdom and breaking it down into a structured way for us”
“Thank you for this training. Incredibly helpful and puts me more at ease and I have a better understanding”
“Thank you! I feel that I have a much less punitive/reductive understanding of the purpose for audits, and have some tangible to-dos to implement for my own group practice!”
Who is this event for?
This course is designed for solo practitioners, group practice leaders, and group practice clinical staff members. It is also suitable for practices that consist of 100% in-person, 100% telehealth, or a mixture of in-person and telehealth treatment.
In-person Practices
Hybrid Practices
Teletherapy Only Practices
Whether you’ve been practicing for decades or just got credentialed, you’ll walk away with concrete strategies to document with confidence and clarity.
I’ve been watching several of your CE programs and, while I’ve always been impressed with your services, I just have to say, your programs are excellently done with production and content and simultaneously warm and accessible. I really appreciate what you do!
Informed Consent
Explain two critical aspects of informed consent to review with all clients who use insurance for psychotherapy.
Medical Necessity
Define medical necessity and apply the concept to a specific client population.
Diagnosis Justification
Identify how to justify a mental health diagnosis consistent with medical necessity criteria.
Progress Notes Review
Describe the process for reviewing a progress note based on medical necessity criteria.
Course Details
3 CE Credit Hour. Self Study
Title: Dealing with Insurance: How Auditors Think and Why (Updated for 2026)
Authors/Presenters: Maelisa McCaffrey, PsyD
CE Length: 3 CE credit hours
Legal-Ethical CE Hours: 1 legal-ethical CE credit hour
Educational Objectives:
- Explain two critical aspects of informed consent to review with all clients who use insurance for psychotherapy.
- Define medical necessity and apply the concept to a specific client population.
- Identify how to justify a mental health diagnosis consistent with medical necessity criteria.
- Describe the process for reviewing a progress note based on medical necessity criteria.
Syllabus:
- Introductions
- Insurance and Client Access to Records
- Open Notes, HIPAA, and more
- Informed consent and insurance documentation
- Policy myths and common mistakes
- The Concept of Medical Necessity
- Definitions and uses by insurance
- The importance of diagnostic assessment
- Stress-free treatment plans for insurance
- Documenting progress and need in every session
- How to Self-Audit Client Files
- Red flags for audits
- Review checklists for self-auditing
- Correcting mistakes in documentation
- Exercise: Review a note using a sample audit form
- Final Reflection and Q&A
Note: Yes! Medical necessity will be addressed in this presentation.
Meet Our Presenters
Presented by
Maelisa McCaffrey (Hall), PsyD
Dr. Maelisa McCaffrey (Hall) is a licensed psychologist, nail design enthusiast, and multi-passionate entrepreneur. With her business QA Prep, she empowers therapists through trainings and consultation on clinical documentation. Maelisa focuses on the “why” behind the usual recommendations and encourages clinicians to think outside the box, while also keeping their ethics intact. A true ENFP, Maelisa aims to make sure all of her endeavors are meeting a need in the community while also allowing for plenty of laughter and fun.
Resources & Citations
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American Counseling Association. (2014). ACA Code of Ethics. Alexandria, VA: ACA
American Mental Health Counselors Association. (2020). AMHCA Code of Ethics.
American Psychological Association. (2022). Behavioral Health Integration Fact Sheet [White paper]. American Psychological Association. https://www.apa.org/health/behavioral-integration-fact-sheet
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct (Washington, DC: American Psychological Association, 2017). http://www.apa.org.ethics
American Psychological Association. (2021). Professional Practice Guidelines for Evidenced-Based Psychological Practice in Health Care. American Psychological Association. https://www.apa.org/about/policy/psychological-practice-health-care.pdf
American Psychological Association. (2007). Record Keeping Guidelines. American Psychologist, 62(9), 993–1004. https://doi.org/10.1037/0003-066X.62.9.993
APA Dictionary of Psychology. (2023, November 15). Informed consent. American Psychological Association. https://dictionary.apa.org/informed-consent
Benjamin A. (2008). Audit: how to do it in practice. BMJ (Clinical research ed.), 336(7655), 1241–1245. https://doi.org/10.1136/bmj.39527.628322.AD
Chow, D. (2018). The First Kiss: Undoing the Intake Model and Igniting the First Session in Psychotherapy. Correlate Press.
Criteria for the Evaluation of Quality Improvement Programs and the Use of Quality Improvement Data, American Psychological Association, American Psychologist. 2009. September Vol 64 Number 6, Pages 551-557.
Cure Act Final Rule: Information Blocking Exceptions. The Office of the National Coordinator for Health Information Technology. URL: https://www.healthit.gov/sites/default/files/2024-04/IB_Exceptions_Fact_Sheet_508_0.pdf
Darby, W. C., & Weinstock, R. (2018). The Limits of Confidentiality: Informed Consent and Psychotherapy. Focus (American Psychiatric Publishing), 16(4), 395–401. https://doi.org/10.1176/appi.focus.20180020
Forester-Miller, H., & Davis, T. E. (2016). Practitioner’s guide to ethical decision making (Rev. ed.). Retrieved from (Hyperlink inserted here for space)
Griswold, B. (2022). Navigating the Insurance Maze (9th ed.). Barbara Griswold, LMFT.
Khan, Y. S., Albobali, Y., & Kamal, L. F. (2022). Improving the quality of structured clinical documentation in a child and adolescent psychiatry outpatient service: Findings from an audit cycle. Asian Journal of Psychiatry, 77, 103268. https://doi.org/10.1016/j.ajp.2022.103268
Los Angeles County DMH Program Support Bureau Quality Assurance Division. (2010, October 5). Assessments [PowerPoint slides]. https://file.lacounty.gov/SDSInter/dmh/162893_AssessmentsandMedicalNecessity10-05-10.pdf
Medicare. (2024). Medicare and Mental Health Coverage. Medicare Learning Network. https://www.cms.gov/files/document/mln1986542-medicare-mental-health-coverage.pdf
Miller, S., Hubble, M. & Chow, D. (2020). Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness. American Psychological Association.
Mitchel, R. (2007). Documentation in Counseling Records, an Overview of Ethical, Legal and Clinical Issues, American Counseling Association. Alexandria VA.
Muecke, J. (2024, April 5). Why I Don’t Do a “Thorough and Structured” Intake. Frontiers of Psychotherapist Development. https://darylchow.com/frontiers/why-i-dont-do-a-thorough-and-structured-intake/
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Office of the National Coordinator for Health Information Technology. (n.d.). Retrieved March 17, 2024 from https://www.healthit.gov/faq/what-electronic-health-record-ehr
Pope, K., Vasquez, M., Chavez-Duenas, N., Adames, H. (2021). Ethics in Psychotherapy and Counseling (6th ed.). John Wiley & Sons, Inc.
Reamer, F. (2010). Documentation in Mental Health Practice: Ethical and Risk-Management Challenges
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Schwitzer, A.M. & Rubin, L.C. (2015) Diagnosis & Treatment Planning Skills. Thousand Oaks, CA: SAGE Publishing.
Thom, R.P. & Farrell, H.M. (2017). When and How Should Clinicians Share Details from a Health Record with Patients with Mental Illness? AMA Journal of Ethics, 19(3): 253-259. 10.1001/journalofethics.2017.19.3.ecas3-1703.
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U.S. Dept. of Health and Human Services. (2013). HIPAA Omnibus Final Rule. Washington D.C.: Author.
Accuracy, Utility, and Risks Statement: The contents of this program are based primarily on the presenters’ extensive combined experience handling legal, ethical, and usable paperwork needs for mental health organizations. Statements about applicability are according to presenters’ understanding of the state of the art and legal precedents at the time of presentation. This program discusses strategies for complying with applicable ethics codes and laws, for improving clinical documentation, and the informed consent process. It may not include information on all applicable state laws. Misapplication of the materials, or errors in the materials, could result in non-compliance with applicable laws or ethics codes.
Conflicts of Interest: none
Commercial Support: none.