Documentation & Patient Requests [Healthcare Compliance Tips]

Ensure you re-review your policies regarding documentation, record retention, and patient requests.

The last tip explained why understanding non-covered services is part of non-clinical duties, which includes reviewing government and commercial insurance guidelines.

And after you understand these guidelines, it is now time to focus on:

Documentation, Record Retention, & Patient Requests

For lack of a better word, I bet increased documentation and paperwork is making your head spin!  We have all seen studies where this is hindering patient care.  Unfortunately, documentation and paperwork are here to stay, but what if I told you there is an easier way around it?

And that would be through utilizing your employees.  Per my previous posts, I discuss how to reinvent your team and the importance of utilizing your employees to help shoulder the burden.  Surprisingly, they may seek increased job duties to boost their motivation and experience, in which you can delegate tasks that would assist you both.

Last, consider hiring a medical scribe.  The statistics in this article share the regulations, duties, and benefits to assist you with documentation and reduced paperwork.

As your paperwork or documentation increases, patient requests probably will continue to rise.  Due to the enactment of EHR systems, patients have the power to review and make changes to their medical and billing records to ensure accuracy.  This is a good time to increase your non-clinical skills by brushing up on federal and state regulations surrounding patient requests.

Per HIPAA and the OIG:

• Medical record documentation must be kept for at least six years from the date of creation. A best practice is to keep them longer, in case an investigation arises (10+ years).
• Requests must be provided within 30 days for onsite and 60 days off-site.
• Patients can’t be denied a copy of their records, even if their balance is unpaid.
• A reasonable charge may be accessed to the patient for copying or mailing records.
• No charge can be accessed for searching or retrieving the medical records.

Documenting properly and retaining records is important now more than ever.  If you delegate these areas, always create compliance policies and procedures surrounding documentation, record retention, and patient requests.

Conclusion

Your patients need you.

Our healthcare system needs you.

It’s time to put up a fight!  You may not be able to change the direction healthcare is going, but your goal is to conquer the system.  This may call for a little creativity, increased research, employee and patient polling, change in policies and procedures, revamp of practice finances etc. to beat the hand you are dealt.

Now is the time to reinvent your team and use their feedback to increase your non-clinical skills and build an effective compliance program.  After review, streamline the process by creating checklists, handy documents, templates, or any other resources that everyone can use regularly.  Utilize paid and free educational resources, consider consultants, professional memberships, or toss ideas around with colleagues.

I am willing to guess you became a practice owner because you wanted the ability to treat patients, autonomy, greater earning potential, or a legacy to leave behind.  Don’t lose sight of your entrepreneurial dream just because healthcare is changing.  I know you are nervous.  We all are.  But, you don’t have to carry this burden alone or suffer in silence. As the old saying goes, “Find a way or make one.”  Don’t give up!

Click here for the next tip in the series.

**The opinions and observations from the group/author are not a promise to exempt your practice from fines and penalties.  Research, modify and tailor the advice to fit your specialty.