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Medical necessity in therapy notes is an insurance concept, not a clinical one, and auditors are checking for four specific elements in every claim. Most of us were trained to document care. This post covers what it takes to document it in a way that holds up under review.

A $630,000 demand. Forty-five days to respond. This is the inside account of what an insurance audit for therapists actually looks like when documentation gaps accumulate across a multi-clinician practice. The clinical work was happening. The records didn’t prove it.