This article was first published in the April 2024 Communiqué
Many registrants write to the Practice Advisory Service asking about what to do when an insurance provider asks them to verify information on a benefit claim. Verifying claims is often a necessary step before a client can be reimbursed. Although such requests often relate to administrative details such as the provider’s credentials, session dates, and billing amounts, registrants are still responsible for maintaining client confidentiality.
What should you consider? Read on to find out.
Informed consent and confidentiality
It is a fundamental responsibility of registrants to maintain client confidentiality at all times, including when requests are made for client information by third parties such as lawyers or insurance companies. Registrants must ensure that clients have consented to the sharing of their personal health information to process the insurance claim. Often, clients provide this consent when they submit their claim to their insurance provider. Only necessary information may be shared to process the claim, e.g., that the session(s) occurred as claimed. (See Standard 3.1: Confidentiality, linked in Related Resources below.)
Reflection question
- Is there evidence the client consented to the sharing of their personal health information to process the insurance claim (e.g., have they submitted a claim form with language to this effect)?
When a client submits a claim to their insurer, does this imply they have provided consent to verify their information?
As noted above, registrants must ensure the client has consented before disclosing information to an insurance provider. It is common for insurers to require client consent to process claims.
Reflection questions
- Can the insurer provide evidence (e.g., a submitted claim form) that the client consented to share their information?
- Does the information submitted by the client match your records?
What should I do if the information I am asked to verify does not match my records?
There are several considerations for this situation.
Honest Mistake
The client could have made an honest mistake regarding some details of the claim. In this case, it may be straightforward to correct the information with the insurance company (assuming there is evidence of consent from the client to do so), or you may wish to liaise with the client about how to address the situation.
Crime and Fraud
The situation is different where intentional fraud may be involved. CRPO’s Professional Practice and Jurisprudence for Registered Psychotherapists eLearning manual discusses a hypothetical situation. See Standard 1.3 linked in Related Resources below and click on “Crime” to expand the topic. Note each situation is unique, and registrants should seek appropriate advice before applying the principles outlined in this scenario to their situation.
Discontinuing Therapy: The scenario linked above mentions the possibility of discontinuing services to the client. Again, this may or may not be appropriate in the situation. The following is noted in the Commentary to Standard 6.3: Discontinuing Services:
Conflicts of interest and discontinuing care
RPs must be aware that when discontinuing service to a client due to an irreconcilable conflict of interest, they must uphold all relevant confidentiality standards and laws.
A registrant would need to decide whether they are able to provide safe, competent care to the client, or whether that is no longer possible. Registrants are encouraged to seek supervision or consultation for guidance.
Confidentiality: As noted above, registrants must maintain client confidentiality at all times except with consent or if a legal exception applies. Consider if there is a consent signed by the client giving you permission to speak to the insurance company, or if the client has given you permission orally.
Consider also that it may be possible, depending on the wording used and the context of the situation, to tell the insurance company that a particular receipt is not valid without providing any personal health information. For example, simply denying the validity of a receipt does not need to confirm whether the claimant was ever a client or not. This can help avoid registrants being placed in an ‘impossible situation’ where they are forced either to breach client confidentiality or acquiesce to insurance fraud.
Other legal exceptions to confidentiality may be applicable depending on the situation, for example, if legal proceedings or a police investigation are involved. Registrants are advised to consult with a legal advisor about these issues.
Reflection questions
- Did the client make an honest mistake or intentional fraud?
- How can I validate or deny the claim without providing personal health information?
I have been asked to provide a treatment report. How much detail should I provide?
Sometimes a request from an insurance company goes beyond simply confirming a session. Upon receiving a request for a detailed report, registrants should first seek express consent from their client, or their authorized representative, to provide the report and discuss the requested content. A report must be provided within a reasonable timeframe, unless there is reasonable cause not to do so. Registrants should ensure that only relevant and requested information is provided and provide clients with the opportunity to review the report prior to submission. Finally, registrants must ensure that reports are sent through secure means. See Standard 5.2: Requests for Reports and our Practice Matters article on Obtaining consent to release information, both linked in Related Resources below.
Reflection questions
- Do I understand the request?
- Do I have the necessary competence to provide the information requested?
- Does the client understand the nature of the information that would be included in such a report?
- Has the client provided express consent for me to provide a report for this purpose? Is the client’s express consent documented in the clinical record?
- Will I charge a fee to prepare the report and does the client consent to pay the fee?
- Does the report indicate whether I am providing an opinion, stating an objective fact, or summarizing information provided by the client?