[00:00:00] Maureen Werrbach: Welcome to another episode of the Group Practice Exchange Podcast. Today I have Tiana Kelly on with me, and we’re gonna be talking about how to protect your practice through stronger compliance and documentation. She is someone who’s been in the clinical field for a handful of years and started a company that brings a wealth of knowledge and experience in compliant documentation practices and policy development.

[00:00:28] Maureen Werrbach: HIPAA standards and chart auditing, and so I’m excited to talk to her today about all things compliance and documentation. Welcome to the Group Practice Exchange Podcast, where we talk about all things related to group practice ownership. I’m your host, Maureen Wach.

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[00:03:06] Maureen Werrbach: Welcome back to another episode. Hi, Tiana. It’s so nice to have you on here and talking about a topic that I feel like. So many people just kind of shy away from or ignore until it kind of hits them in the face. So I’m excited to have you on, 

[00:03:20] Tiana Kelly: right? Yes. I’m so excited to be here to talk a little bit about compliance and hopefully offload some of that fear that does make people not focus on compliance until they’re forced to focus on compliance.

[00:03:33] Maureen Werrbach: Exactly. So I know compliance and documentation. It’s something that makes clinicians nervous. They sort of do what they think is enough and then hope it’s enough. But what I do notice is that when people become group practice owners and then they have the livelihoods of a whole bunch of therapists, the pressure of compliance and chart auditing and all this stuff becomes even more front and center.

[00:03:58] Maureen Werrbach: But I know a lot of practice owners will just sort of. Hope that everything is going well. Trust their clinicians to just know how to do it. All right, and so I’m excited to have you on, but I want you to start by letting people know how you got into this. I know you’re a clinician, but I also read in your bio that you have like a doctorate in like something compliance related, 

[00:04:17] Tiana Kelly: right?

[00:04:17] Tiana Kelly: Yeah. Kind of sorta a doctorate in prevention science. So definitely has some applicability to compliance. ’cause compliance is all about like risk management, trying to reduce our risks where we can and strengthen protection where we can. So, yeah, a little bit about me. I am a licensed professional counselor in the state of Pennsylvania, and so I work with move forward counseling in Pennsylvania and also am the compliance officer at Move Forward.

[00:04:44] Tiana Kelly: So I have really worked over the last couple of years to develop our compliance program from the ground up, and I’m now sort of in the phase where I’m working a lot one-on-one with our clinicians to say for instance, like strengthen our documentation. There’s. You know, lots of other things I do in that role as well, but that’s a, a key piece of it to try to make sure, you know, across the board at our.

[00:05:04] Tiana Kelly: Company that we’re all practicing within compliance. And then in addition to that with our owner, Allison Pigeon, who, you know, some of you may be familiar with, we recently just launched Private Practice by Design, which is a consulting organization. She does some business consulting services and I am doing some compliance consulting services, uh, to kind of take, you know what I’ve.

[00:05:27] Tiana Kelly: Learned and implemented and done it move forward and spread that knowledge, spread those skills to other practice owners who might, you know, be in a, in a similar boat of needing to like really develop and strengthen their compliance programs. 

[00:05:40] Maureen Werrbach: So, to jump right in, what do you see as being the most common compliance gaps in group practice?

[00:05:47] Maureen Werrbach: That’s our listeners. I know looking at what those common gaps are, I think is something that they’re all kind of looking to see. I the only practice that sees these gaps or is this a common thing? 

[00:05:57] Tiana Kelly: Yeah. You know, I would really say the biggest gap, and this is gonna kind of sound like a weird answer, but we’ll work through it together, is like just not doing compliance.

[00:06:07] Tiana Kelly: And what I mean by that is, for instance, like. Not doing regular chart auditing. Right. Just not, it’s the thing that I, I put on my radar every single week, but it’s the thing that gets pushed every single week. ’cause there’s a million other things that pop up on that to-do list. And it just feels like, well, no one’s coming in and, you know, doing any external audits or investigations or anything like that, it’s so like, it can wait until next week.

[00:06:30] Tiana Kelly: Right? And so we just get in this habit of continuously. Putting those things off. And so that I think is the first piece is just like not really doing the things that you need to in order to be in compliance with state and federal law, with our ethics codes, with our payer requirements. Another piece of that could be, for instance, like not having appropriate policies or procedures.

[00:06:55] Tiana Kelly: An example of that could be like, do you in your policies, the procedures manual have. Something outlined for staff on like how they should report compliance concerns. Do you have a channel for that? Are are clients and staff aware of how to do that? So that’s what I kind of mean by like just not doing compliance, not even being aware perhaps of what is needed in order to maintain compliance in a private practice.

[00:07:21] Maureen Werrbach: I was gonna say that, um, when I worked in a nonprofit decade and a half ago, this is exactly what was happening. So there was no chart auditing until Medicare would come once a year to do their audits, and the week before we would work. Like all day for a whole week doing nothing but not seeing clients, not doing anything, but looking at our charts over the past year, like that was, their process was chart auditing once a year and spending, I mean, 40 plus hours looking at every single note from, you know, like over a year ago, which.

[00:08:01] Maureen Werrbach: How can you really do that? You know? What are your thoughts on what’s an appropriate chart auditing schedule every week? 

[00:08:09] Tiana Kelly: I think. Every week. Yeah. I think every week and every practice is gonna have to kind of find their groove with this. And I think it’s also dependent too, like do you have a separate compliance officer?

[00:08:20] Tiana Kelly: Sometimes is designated like it’s a therapist also doing some compliance duties or, or you as the practice owner, also the compliance officer. And that’s gonna help. Determine like how much time do I have versus how much time do I allot for, you know, another one of my staff to take over some of this. But I think every week to just at, you know, at the very minimum, you’re showing your due diligence, right?

[00:08:42] Tiana Kelly: I’m in there, I’m examining charts every single week. You know, I’m pulling multiple therapists, multiple files. That looks better than saying, you know. Hey, I, I check ’em out the first Monday of every month. That’s better than nothing. Yeah. Like I’ll definitely give that credit, but it, it does sound a lot better if you’re able to say, Hey, you know, every week I am in there doing that kind of work.

[00:09:04] Maureen Werrbach: Yeah. What do you see as the most common, um, documentation, mistakes when you do a chart audits, what are the common things you see? 

[00:09:14] Tiana Kelly: Yeah, one of the biggest ones is just like timeliness. And of course there’s some variance here in terms of, well, state by state, but definitely like by your payers. Now, I always say like industry standard across the board, we should all be aiming for that like 24 to 48 hours getting in documentation after each session.

[00:09:34] Tiana Kelly: Um, but sometimes that doesn’t happen. And when that doesn’t happen, you know, one of my first go-tos is like, just. Documenting like that, that didn’t happen. And I know, you know, that feels scary for people ’cause it’s like, I don’t wanna call myself out, but look like if insurance is in there or whoever’s in there doing an audit, they’re gonna see that it wasn’t done on time.

[00:09:53] Tiana Kelly: It’s gonna look better for you to just say. Hey, it wasn’t done because of time management or because the EHR went down or something like that. Mm-hmm. Like just acknowledge it wasn’t done. I get it. And I’m human and here’s the reason why. Um, so definitely timeliness comes up as like a, a big area needing improvement for therapists and for practices also miscoding, and whether that’s.

[00:10:17] Tiana Kelly: Intentional, which is a huge issue, right? Or unintentional, just kind of human error. The day is rushing by. I haven’t really been able to stop and watch the clock and you know, all of this stuff or you know, whatever the case might be, but that, that’s a huge one and can have some really negative implications.

[00:10:34] Tiana Kelly: You know, now we’re talking about. Fraud, for instance. So being really diligent about paying attention to your start times, your stop times, what you’re capturing as your duration for session and how you’re coding that, right? 9 0 8 3 7 versus 9 0 8 3 4. That’s one way to really strengthen some protection against the risk of intentionally unintentionally committing fraud.

[00:10:55] Tiana Kelly: And then, you know, I’d say the third biggest one is kind of like a, like a proofreading error. So this could be just. Generally like. Again, we’re moving throughout our days. We’re moving very quickly. I’m gonna do all of my notes after all of my sessions, and I’m calling this client by this name when it actually isn’t this client.

[00:11:16] Tiana Kelly: Like I’m kind of in the wrong session sort of thing. Um, or maybe I am misusing pronouns. Maybe I am not completing the note in its entirety. Right. So I might leave the mental status exactly the same from session to session or the plan exactly the same from session to session. And after a while, that starts to look cloned.

[00:11:36] Tiana Kelly: Yeah. If you’re an insurance based practice, that, that’s definitely gonna raise some red flags. 

[00:11:41] Maureen Werrbach: Yeah. The benefit, but also the hindrance to like EHRs, having things like automated in a lot of ways. Or where, where you can just click the previous note and have it duplicate it. Helps with getting things done quicker, but not necessarily always when it comes to accuracy.

[00:11:58] Tiana Kelly: Right, right. Absolutely. I think it, having that autopopulate feature I think can help be a nice foundation for us from note to note, but I am always recommending like going in there, there is. Nobody presents exactly the same every single time, right? So there’s always something that you can go in there and make some modifications to, but I think it really sometimes takes like a trained eye to be able to see like, okay, what was that change in their mood?

[00:12:24] Tiana Kelly: For instance, how can I modify this? Mental status exam, or how can I be more intentional about talking about plans and homework and tentative agendas for next session to make sure I’m altering that plan section just about every session. 

[00:12:39] Maureen Werrbach: Yeah. What do you do in your practice when you see or have clinicians who are engaging in some of these documentation mistakes or compliance related mistakes?

[00:12:51] Maureen Werrbach: Because I know one part of the issue for practice owners is. Having a system for tracking and finding. These errors, but the second half is like, what do I do from a performance management or employment space when those issues come up, especially like, you know, I guess it’s different. We, and we’ve had this experience, I’ve had my group practice for over a decade, so like the longer you have a practice, the more likely it is that a compliance issue will come up.

[00:13:20] Maureen Werrbach: And I, I’ve had an experience with a HIPAA breach with a clinician before and like obviously. The way you handle that is very different than, say, a clinician who’s a week behind on notes consistently. Right. So what are some of the. Things that you’ve seen that, like how do you deal with it? What is a, you know, a good way to deal with it as a leader?

[00:13:40] Tiana Kelly: So I’m in our files every week and we have about 65 therapists at this point in time. So each therapist gets a chart audit. A couple times a year that’s constantly changing and evolving. That number of times, just depending on how many staff we have. ’cause there’s one of me and you know, 65 of them, but a couple times a year they get a chart audit and you know, I go kind of month to month.

[00:14:06] Tiana Kelly: So like we’ll take. You know, July, August, I will work on chart audits for that month and then I send them off to our COO to look at and kind of review, and I will highlight for her any like big, glaring errors that you know need addressed. I might need some like individualized attention. From there, she passes them on to the clinical supervisors and then it’s kind of up to the clinical supervisors how they want to address it.

[00:14:30] Tiana Kelly: If they wanna pull up the audit forms and go through, you know, line by line. The feedback that I offered, if there is any, like glaring issues, I mean that point in time, I think it is probably very individualized as far as what the approach is that’s taken. But I imagine, you know, it’s, it’s a conversation around how do we make sure that you are documenting your start and stop times accurately?

[00:14:52] Tiana Kelly: How do we make sure that you are. Documenting in a timely way or you know, having a conversation around like what are the barriers to doing that? 

[00:15:00] Maureen Werrbach: Yeah. 

[00:15:00] Tiana Kelly: So that’s kind of like month to month what our process looks like Now for some of that stuff where it borders up against like, oh, this is, this is law and we definitely need to have this, like good faith estimates, for instance.

[00:15:12] Tiana Kelly: Yeah. If I notice those are missing, I will directly reach out to our administrative staff who’s responsible for that, to like make sure that it doesn’t get lost in the sauce and they. Handle that. Same thing with like billing. If I notice that there’s some billing errors made, I will reach out directly to billing to just say, Hey, like take a look at this file.

[00:15:31] Tiana Kelly: You know? And they handle from there what happens from a billing end just to make sure we are a hundred percent in compliance, you know, or at least to the best of our ability. 

[00:15:40] Maureen Werrbach: So for practices that are trying to work on staying compliant, maybe they’re listening to this and they’re kind of. Putting compliance at the forefront of their minds when it comes to things that they wanna work on in the next quarter.

[00:15:54] Maureen Werrbach: Um, what are some ways that they can start to focus on compliance or become more compliant without adding more stress or red tape around clinicians’ workloads? Because I know that’s the big piece is like practice owners are always trying to find ways to reduce administrative burden on the clinical team.

[00:16:12] Maureen Werrbach: And so how can we balance that? 

[00:16:15] Tiana Kelly: Yeah, so I’ll kind of answer this like two parts. So from the practice owner standpoint, or again, if you’re, um. Relying on like a separate compliance officer. I think one of the things that was most helpful for me in the very beginning was just like reading, reading, reading, reading, reading.

[00:16:33] Tiana Kelly: Like anything compliance related that I could get my hands on. And still today that I can just read and become more knowledgeable. ’cause this really is, I mean, as soon as you delve into hipaa, it is a lifetime worth of reading. Yeah. And trying to understand. So it’s like if you can really familiarize yourself with.

[00:16:51] Tiana Kelly: The Health and Human Services website, for instance, where all of our HIPAA information is housed. If you are an insurance-based practice, it’s not fun or glamorous in any way, but if you can sit down and really read those insurance manuals and understand like what is required of the practice, what is required of therapists, I think that’s like step one in developing any kind of compliance.

[00:17:14] Tiana Kelly: Program. And then I think it’s really a matter of like making sure you’re training your staff on what is required and then going slow with that. So for instance, you know you’re gonna have various documentation standards and it’s gonna be really. Tempting and enticing to like throw that out all at once and be like, do this now.

[00:17:35] Tiana Kelly: And what I have really learned is that doesn’t work and it, you know, works better to kind of chunk things and focus on some things at a certain point or for a certain matter of time. You start to see everyone’s getting the hang of that. And this, I’m talking like through your chart audits. People are getting the hang of that.

[00:17:52] Tiana Kelly: So then you might start to add some more criteria, right. And get a little bit more strict and stringent around another area. And you’re just kind of constantly upping the criteria. Yep. While you know, all along recognizing them as human beings and understanding that like, hey, yep, I know this is a lot.

[00:18:09] Tiana Kelly: And I will often like in documentation, consults with our therapist, like acknowledge that. ’cause I’m still a practicing therapist, like I still have to. You know, add this extra stuff that I’m learning about, which is an extra administrative burden for me as well. So I just kind of like say that, right?

[00:18:24] Tiana Kelly: Like I get it. I know I wasn’t doing this up until a week ago, until I learned about it. Now I’m doing it. Now we’re all doing it kind of thing. So I think if you can really just try to put like human first therapist first, like understand that this is a lot. We get it. We understand that, and we have to do it right.

[00:18:42] Tiana Kelly: It’s part of our jobs to document X, Y, and Z or to uphold, you know, X, Y, and Z policy. 

[00:18:49] Maureen Werrbach: I was gonna say, you mentioned making changes and not doing it quickly. I think that’s something that. Took me a long time to learn as a practice owner because maybe a little bit A DHD, but a little bit of just, I’m a quick decision maker and then I wanna check it off and you know, get it done and move on to the next thing is learning the art of making slower changes.

[00:19:10] Maureen Werrbach: And I know in our practice now when we make changes, sometimes it takes a whole year to change something that clinicians and admin will be like. This was like the slowest, like we’ve only made two changes in the practice, but they took all year long because what we learned was you have to like almost go through all the seasons with like a particular decision that you’re making.

[00:19:33] Maureen Werrbach: So like whether it’s like what is your PIP strategy, when people have performance issues or what’s your. Process for documentation and compliance. There are so many variables that you might not be aware of or think about when you’re initially making a decision. So the slower you can make that decision, the more likely it is that you experience more clinician behaviors that can.

[00:19:55] Maureen Werrbach: Remind you to like, oh, we should add that into the policy around compliance. And I think when we make decisions quickly, we end up having to like edit it a bunch of times throughout the year because we were like, oh wait, we didn’t think about this part of it. Wait, we now have to add this. Which means then we have to go back to the clinicians to let them know, actually we’re changing our policy a little bit.

[00:20:12] Maureen Werrbach: You actually have to do this in this timeframe instead of this one because we didn’t think about. Insurance A that has, you know, a more stringent compliance expectations than, you know, the other insurances that we take. And so I always see it as like a, a large ship and you, you have a big practice like I do.

[00:20:30] Maureen Werrbach: So every change we make, it’s just like, it’s such a slow moving target to like actually see that change come to fruition. And so it’s. I just wanted to kind of acknowledge the common humanity in that, because I think a lot of people think when they make a decision, practice owners feel like they need to implement it and it needs to like be done by next month.

[00:20:50] Tiana Kelly: Right, right. Yeah. And I think that transparency there is really imperative. You know, to just acknowledge like if you have made a change and then you have to go back on that change or make that change even more strict and stringent. Like just acknowledging some of the reasons why. 

[00:21:06] Maureen Werrbach: Yeah. 

[00:21:07] Tiana Kelly: People tend to, depending on what the change is, tend to do better with an explanation as to like, oh, okay, I understand they’re not just doing it ’cause they’re naggy and Yeah.

[00:21:16] Tiana Kelly: You know, trying to make our jobs difficult. They’re doing it because, you know, they learned more information or there is a new requirement or something like that. That tends to land better with people than just like, I know we just made this change here. Do this again or do this instead. And yeah, that just being able to be patient and feeling okay with the, like, anxiety that can come up when you know like, Ooh, we’re supposed to be doing it this way, but like, we can only move as fast as the, you know.

[00:21:45] Tiana Kelly: 30 plus, 50 plus, 60 plus people that we’re trying to implement this change with can move. I mean that’s, you know, for, again, 65 therapists for our practice, that’s 65 people, that’s 65 plus different variables like what’s going on in their lives. That might make change really difficult right now. 

[00:22:03] Maureen Werrbach: And I wanna share that.

[00:22:06] Maureen Werrbach: My attorney had once said many years ago, like when it comes to law, at least like there’s in this arena that there is some. I don’t wanna say flexibility might not have been the word that she used, but like if you can show that you’re making changes in the direction, like it’s one thing to be like, close your ears, close your eyes and be like, I didn’t know.

[00:22:27] Maureen Werrbach: That’s not a good enough answer. Mm-hmm. But if you can share that you’re like shifting your policies in a way that would meet the law. Right. Or meet ethics expectations. There’s more of a likelihood for not leni, but like. Lence, I guess is in, in terms of like if you’re actually doing something that’s, that you’re not supposed to be doing.

[00:22:50] Maureen Werrbach: If you can show that you’ve been aware of it last month, let’s say, and you’re starting to make shifts in your policies to rectify that, that actually is a show of a sign of good faith and like more likely than not that you’ll be. Fine. And she said this like around just the rushing of making decisions immediately.

[00:23:08] Maureen Werrbach: She’s like, it’s better to like put your thoughts together on how to rectify this and slowly make the movements towards that. Because even just the awareness and the shift to like getting to where you need to be is a sign of good faith and we’ll make it more likely that you won’t actually get in as much trouble as you might think you will.

[00:23:26] Maureen Werrbach: ’cause I, I think a lot of us assume that we’re gonna. Have our whole practice taken away over a minor issue that we didn’t, weren’t aware of or we’re still trying to fix. So I remember when she said that it was, it relieved a lot of pressure in terms of, you know, engaging in, having clinicians, maybe engaging in things that we weren’t fully aware of or whatnot.

[00:23:44] Maureen Werrbach: That there’s always, there’s room for growth and the people who make decisions take that into consideration. 

[00:23:51] Tiana Kelly: Yeah, I would totally echo that. And I, I think that that is. Spot on that really those in charge of regulating hipaa, our ethics code, state laws, things like that. I, I think it’s very much like an employment practice where we wanna see people succeed, right?

[00:24:07] Tiana Kelly: We don’t wanna fire them, we don’t wanna have them in that position. So we’re gonna try to give them, you know, all the tools and every opportunity and every chance that we possibly can before, you know, having to resort to some. Detrimental outcome. 

[00:24:21] Maureen Werrbach: Yeah. 

[00:24:21] Tiana Kelly: And I think that that is very much, or at least I hope that is very much the same for some of our, like regulating bodies, that they’re not trying to shut all of our doors down.

[00:24:30] Tiana Kelly: Right. That wouldn’t be good. Right. And so they’re, they’re looking for those things. They’re looking for us to be able to say like, we’re aware and we have a plan and we’re working on it. And really, I mean, it’s truly the best that you can do. As we were just talking about, like when you’re managing multiple, multiple people, you’re just not going to be able to say like, here’s the change, do it.

[00:24:50] Tiana Kelly: Have it done yesterday. 

[00:24:51] Maureen Werrbach: Yeah, exactly. So I know we’re at the end of our time here. If people are wanting support, I know you offer. Compliance related support. How can my audience reach you if they have questions about it? 

[00:25:03] Tiana Kelly: Yeah, the best first step would probably be reaching out to our website, so private practice by design.com.

[00:25:10] Tiana Kelly: We have a contact page on there. And our email address is also listed on there for just general inquiries if you’re interested in business consulting services or compliance consulting services. And then we, you know, once we receive that inquiry, would reach out to you within, you know, like 24, 48 hours, kind of the standard and see what we can get set up and get established.

[00:25:30] Tiana Kelly: And we also have. Various social media channels, LinkedIn, Facebook, Instagram. So that’s another place to just check us out and see what we’re up to. 

[00:25:39] Maureen Werrbach: Awesome. Well, I appreciate you coming on. Yeah, thank you. Thanks for listening. Give us five stars on whatever podcast streaming service you use, and I’ll see you next week.