Clawback protection guidelines

Have more questions? Submit a request

Headway and our payer partners always expect that you’re using good faith judgment in choosing the right CPT and diagnosis codes for sessions, and that you are keeping notes (on Headway or elsewhere) that support this. We aim to always protect you from “clawbacks” (i.e., avoidance of recouping payments already made) on sessions you’ve submitted. Here’s a quick refresher on exactly how this works, and what you can do to keep things running smoothly on your end:

Headway will always guarantee you’re paid in the event that we’ve made a mistake or given a client inaccurate information regarding their coverage, even if there are complications with their claims.

  • This could include instances where we incorrectly told a client you were in their network, if their benefits ended or changed without our system catching it, or there was a qualification or authorization required on their plan that we didn’t know of when they booked.
  • In any of these cases, we will ensure that you are paid your contracted rate for your time and services, whether your client was  ultimately covered or not.

In the event of a provider error, Headway may reach out to discuss the situation and any implications to how the claim will be paid.

  • This could include:
    • Sessions coded in a way that does not align with  CPT/ ICD-10/ or payer guidelines
    • Instances where the CPT or diagnosis codes chosen don’t represent the services performed or session notes
    • Lack of notes produced for a session upon request, or lack of response to a notes request within three business days
    • Lack of response from a provider to a client/Headway team in the event of a cancellation fee or billing dispute

The great news is that these recoupment circumstances are completely avoidable. To ensure this, keep a few things in mind:

  • Always code accurately and compliantly. We offer some guidelines in our Help Center, but we encourage you to consult other resources of your choice as well.
  • Follow payer guidelines for Progress Notes, which generally means following a SOAP or DAP template
  • Consider “medical necessity” when coding — e.g., does the client have an applicable behavioral health diagnosis for this type of care?
  • Be responsive to clients or Headway team members when asked about session coding, cancellation fees or circumstances
  • Keep your notes on Headway or another HIPAA compliant platform, and be sure to supply them promptly if requested. (Clients on Headway are prompted to sign our Standard Forms upon account-creation, so you can be assured that their privacy rights are protected throughout this process) 

We’ll always reach out to you directly if there’s ever a complication or question about the way something is submitted. We never intend to surprise you or unknowingly edit your payments, so this will always be a conversation if it comes up. You can review the provider guidelines anytime, and we’re here to help and give feedback!

Articles in this section

Was this article helpful?
1 out of 1 found this helpful