I have worked with hundreds of substance use disorder facilities, and leadership teams often begin our conversations by explaining that they are not in the business of committing fraud. Their clinicians are intelligent, their managers are committed, and their organization exists because they genuinely want to help people recover. They are doing the best they can, and they believe their teams are doing the same.

In my experience, they mean every word of it.

When I review records, I rarely uncover a deliberate scheme designed to bill for services that were never provided. What I find far more often are foundational documentation requirements being missed by good people working inside organizations with meaningful missions.

That mission-driven distinction matters, but it does not make the risk disappear.

Good intentions do not replace compliant documentation. Intelligent clinicians can still use the wrong template. Experienced managers can believe a workflow is functioning when staff have quietly developed workarounds. An organization can be growing, revenue can be strong, and claims can be paid while documentation problems continue building underneath the surface. Payment is not proof that the record will withstand a future review.

Ten charts will not tell leadership everything. But they can reveal whether what is happening in practice resembles what leadership believes is happening.

Ten Charts Are a Reality Check

I am not suggesting that the CEO become a chart auditor. CEOs should not be spending their time determining whether every ASAM dimension was sufficiently supported or whether every group note was adequately individualized.

Leadership does, however, need to remain close enough to the documentation and the internal audit efforts to understand what is happening inside the organization.

A CEO could ask the compliance and clinical management teams to randomly select ten records and return within one or two weeks with an honest assessment of what they found. The request should be made with enough immediacy that the records reflect ordinary practice. This is not the time to select the ten strongest clinicians, find the ten cleanest records, or quietly correct everything before presenting the results.

This is not a “gotcha” exercise either. The purpose is to see what a payer, auditor, or regulator could see if those same records were selected tomorrow.

Start Where the Risk Actually Exists

The ten records should not necessarily be distributed evenly across every program. Leadership should first identify which service creates the greatest exposure for its organization.

For one facility, that may be PHP because of its volume, reimbursement, documentation expectations, or the need to continually support the patient’s continued stay at that level of care. For another, it may be withdrawal management, residential treatment, or IOP. The highest risk service depends on where the organization is providing the most care, receiving the most reimbursement, experiencing the greatest operational strain, or facing the most payer scrutiny.

I would concentrate most of the sample within that service and use the remaining records to examine other meaningful variables. That might include longer lengths of stay, different clinicians, newer employees, or a payer that frequently questions services.

The goal is not to create a statistically perfect audit from ten records. The goal is to select ten records capable of telling leadership something it does not already know.

What Ten Charts Can Reveal

Ten records can expose far more than a missing documentation element. They can reveal how the organization actually operates.

They may show whether clinicians understand how to individualize progress notes or whether the documentation has become generic and repetitive. They can uncover copy and paste patterns that management did not know were occurring or reveal that a new employee was trained to use the wrong template and has now been documenting incorrectly for months.

They can also show whether technology is supporting the clinical team or quietly contributing to the problem. They can expose variation among providers, gaps in education, ineffective supervisory review, and a culture in which staff are completing documentation because the system requires it rather than because the record must tell the patient’s clinical story.

Most importantly, the review can provide insight into the organization’s compliance maturity. Does the team recognize a problem when it sees one? Can management explain why it occurred? Is someone willing to raise the concern, or does everyone feel pressure to report that everything is fine?

When a Checklist Creates False Comfort

In one organization, the team was using an ASAM checklist programmed to include narrative support. On the surface, this appeared to be a strong documentation tool. The required information was built into the workflow, and leadership believed the checklist was helping clinicians provide individualized support for each patient.

When the records were reviewed, we found that the same narrative was being copied and pasted from one patient to another.

The finding caught leadership by surprise. The tool existed, the workflow had been established, and the team had been trained. From their perspective, the safeguard was already in place.

But the existence of a checklist did not prove that it was being used correctly. That one finding revealed an education gap, a workflow problem, a technology issue, a supervision concern, and a documentation culture that had allowed repetitive language to become routine.

That is what ten charts can do. They can take something leadership believes has been addressed and show how it is actually functioning when care is being delivered.

Strong Revenue Does Not Answer the Documentation Question

Revenue growth can create a dangerous sense of comfort, particularly when an organization is expanding quickly. More patients are being served, programs are growing, claims are being paid, and the organization appears to be succeeding.

Meanwhile, the workforce is changing. New employees are joining the organization, roles are shifting, and staff may be trained by others who do not fully understand the requirements themselves. Technology that worked for a smaller organization may no longer support the volume. Supervisors may be carrying larger teams, while clinical leaders spend so much time solving immediate operational problems that routine spot checks quietly stop happening.

This does not mean the team is careless. It means growth can outpace the workflows, technology, education, and oversight needed to support it.

Good revenue tells leadership that claims are being paid today. It does not tell leadership what will happen if a payer looks back at the records supporting those payments.

Leadership Should Want to Hear What Is Wrong

Clinical and compliance leaders should never be afraid to tell the CEO that they found a problem. In fact, leadership should expect them to find something.

An organization that continually reports that everything is fine is not necessarily an organization without risk. It may be an organization that is not looking deeply enough, measuring the right things, or creating enough safety for managers to bring concerns forward.

Leadership does not need people who simply confirm that existing processes are working. Leadership needs people who will identify a weakness before a payer does.

That also requires the right response when a problem is reported. Instead of asking, “How did you let this happen?” leadership should ask, “What allowed this to happen, how far did it spread, and how will we know the correction is working?”

A compliance team that brings forward uncomfortable findings is doing its job. A clinical manager who admits that a workflow failed is showing leadership there is an opportunity to correct the problem before it becomes an external finding.

The real danger is not discovering that something is wrong. The real danger is discovering it for the first time in a payer audit.

Correct Something and Then Look Again

Once the ten charts have been reviewed, leadership should ask the clinical and compliance teams to identify the top one or two issues that can be corrected immediately.

Trying to fix every observation at once usually produces another training session, another email, and another policy reminder that staff are expected to absorb while continuing to care for patients. That can create more compliance fatigue without producing meaningful change.

Instead, leadership should require a focused response. What was found? What caused it? What specific correction will be made? Who is responsible for implementing it? How will the organization verify that the correction reached actual documentation practice?

The team should then return in 30 to 60 days with results from another review. Leadership should see evidence that the corrected process is being used properly, not simply hear that staff completed training.

The finding should also be added to a continuing oversight list. Otherwise, the organization may correct it temporarily and discover six months later that the same issue has quietly returned.

Training completion is not the outcome. Correct documentation is the outcome.

Pull the Ten Charts

Some of the greatest financial exposure begins with items that appear small. The note does not clearly describe the patient’s progress. The treatment plan is not connected to the services being delivered. The record does not support why the patient continues to need the current level of care. Group documentation does not establish the required clinician to client ratio. The same narrative appears across multiple patients.

These findings do not necessarily mean the services did not occur or the patients did not need treatment. But if the documentation does not contain what the payer requires, the payment may be denied or recouped.

If you lead an SUD organization, ask your compliance and clinical management teams to pull ten random charts. Ask them what those records reveal about your workflows, education, provider variation, documentation culture, and compliance maturity.

Then listen with an open mind. Do not expect perfection, and do not punish the people willing to show you where the process is breaking down. Expect honesty, a focused correction plan, and evidence within 30 to 60 days that the correction is working.

Ten charts are not a complete compliance program or a substitute for routine auditing, monitoring, education, and independent review. But they can give leadership an honest view of what is happening when no one believes the CEO is looking.

You may be doing the best you can. Your clinicians may be intelligent, committed, and deeply invested in the people they serve. Your managers may care just as much as you do.

Pull the charts anyway.