WTF Do Insurance Auditors Want?! A Dietitian’s Guide to Not Screwing Up Your Notes
You’re running your private practice, juggling client care, training your dietitians… and then bing-bop-boom (cue Kendrick Lamar) - you realize you could get audited and aren’t 100% sure you’re doing things the right way. Or, maybe you just got hit with an insurance audit request.
Suddenly you’re freaking out and doom-scrolling through chart notes hoping your documentation is “good enough” and you’re not going to get “in trouble.”
Friend, let’s take a deep breath.
Ensuring your documentation meets insurance standards and audit-proofing your practice doesn’t have to be a labor-intensive, panic-inducing undertaking. Whether you’re a seasoned group practice owner or new to accepting insurance, having streamlined charting templates, internal audit processes, and compliant documentation is exactly what will keep your practice secure and stress-free (or at least less stressful LOL).
In this blog, I’m breaking down the must-haves for insurance documentation, internal audits, and charting templates to keep you prepared and protected.
And if you’re ready to really get your sh*t together? Join me for my upcoming masterclass, “Audit-Proof Your Practice: Mastering Insurance Documentation with Confidence!” on Thursday, March 27th at 3:30 PM (CST). RSVP here to join live or use code AUDIT10 at checkout for $10 off to get the post-event recorded version (code expires 3/27 at 3:30 PM)!
Let’s get into it…
1. Make your chart template compliant
If your charting template isn’t meeting minimum documentation guidelines set forth by insurance payers, then you’re doing it wrong. You may ask, “Maggy, what do you mean by that??”
What I mean is if anything is needed for compliance, you need to create specific questions or incorporate required fields into the template for the you or your dietitians to complete.
The biggest mistake I learned was trying to REMEMBER in every note what needed to be in there.
Instead, make sure every charting template includes:
Service provided (CPT code)
Client’s medical condition (ICD-10 code)
Date of visit
Total time spent with patient (start/stop time, total minutes)
Reason for visit (chief complaint)
Medical history
What you’re doing about it (assessment, plan, education, goals)
When you’ll see them next (follow-up plan)
Provider’s electronic signature that locks and signs the note (include full name and credentials)
Don’t just wing it. Your templates should guide your compliance and make it a no brainer- not leave room for error by relaying on your memory every time.
2. Document good enough
You can chart as much or as little as you want, but make sure that:
Documentation matches the codes you bill.
Notes are clear, consistent, complete, and legible.
Client medical records include identifying info (name, DOB, photo ID, insurance ID, etc.).
Yes, there’s perks to documenting alot (like remembering your client’s dogs name and their Starbucks order) - but insurance doesn’t care if this is or isn’t here. So, remember some type of charting is for YOU as the clinician to remember things.
On the flip side, there are also perks to documenting as little as possible because it takes less time to chart less.
At the end of the day, prioritize what insurance wants, then add in what you prefer. Your notes don’t need to be perfect - they just need to be good enough.
3. Stay in the know with payer guidelines
Documentation expectations vary slightly depending on the payer. And yes, reading through their policies as dry and boring as it sounds- but it’s absolutely essential.
To stay up-to-date:
Bookmark or download guidelines from major payers you work with
Set up a reminder to check these quarterly
Sign up for provider email newsletters from major payers, as this is where they will send out updates
Here’s an example of the documentation guidelines from major payers that can serve as a vital resource for you:
United Healthcare (Chapter 12 is where it’s at!)
BCBS of TX (check your state’s version as rule may vary)
Aetna (page 30 is 🔥 for this)
4. Build an internal audit system
Don’t wait for an insurance company to audit your notes- be proactive. Regular internal reviews help prevent mistakes, catch red flags early, and boost your team's documentation game.
So let’s create an internal audit system where you audit your own notes (if you’re solo) or your team’s notes (if you’re group) on a quarterly basis.
You may ask, “But, Maggy - how do I do that?!”
Here’s how my friend…
Establish a note audit frequency: I generally recommend the following,
New RDs (0–3 months): 25 notes/quarter
Mid-level RDs (4–6 months): 10 notes/quarter
Experienced RDs (6+ months): 5 notes/quarter
Create an audit checklist:
Client’s full name
Client’s date of birth
CPT code
ICD-10 code
Date of visit
Total time spent with patient
Reason for visit
Medical history
Assessment, plan, education, goals
Follow-up date
Provider’s electronic signature with full name and credential that locks and signs the note
Does documentation support the billed CPT/ICD-10 code?
Is the information in the chart note clear, consistent, complete, and legible?
Was the note locked and signed within 24-48 hours of the session?
Was there an addendum? If so, was there a new entry, date record, details of amended information, and new signature?
Train your team (and yourself!) on your practice’s documentation practices at onboarding, again annually, and always give feedback based on audit results. Internal audits aren’t about “catching” people - they’re about protecting your practice and training your team to be doing things the right way.
5. Watch the audit-proof your practice masterclass
Still unsure if your documentation would hold up to an audit? Feeling overwhelmed by what “audit” or “compliant” even means?
I’ve got you, friend. Come watch live or snag the recorded episode of:
📢 Audit-Proof Your Practice: Mastering Insurance Documentation with Confidence
🗓️ Thursday, March 27th | 3:30–5 PM CST
💻 Virtual
💰 Free for Dietitian Business Network members | $30 for non-members
👉 RSVP here to join live or use code AUDIT10 at checkout for $10 off to watch the pre-recorded version (expires 3/27 at 3:30P)!
In this session, we’ll dive deeper into:
More documentation best practices
Examples of audit-approved chart templates
Best practices on training your team
Answering your audit and documentation questions live
And what to send me if you want a test audit!
Walk away with clarity, templates, and confidence. Let’s make sure your charting works for you- not against you!
Got questions about the masterclass, need help cleaning up your charting system, or want me to run a mock audit of your practice? Send me an e-mail- I'm here to help you build a compliant, confident, audit-proof practice