Risks Associated with Slow Medical Record Completion

There are major risks associated with slow or delayed completion of medical records. This week we cover compliance risks, ranging from incomplete memory to ethics and right of access. Watch the video to learn more!

Transcript:

Last week, we talked about the timeliness of the completion of documentation after a service is rendered to a patient, how quickly do you have to wrap up that medical record? And we talked about the timings, what most indicate. You know, we talked a lot about Medicare, because Medicare really kind of sets the standard that a lot of others use in their guidelines and requirements. They indicate as soon as practicable after it is provided in order to maintain an accurate medical record. And of course, BlueCross BlueShield said 24 to 48 hours at the very latest. UHC said at the time of the service being rendered, or very soon thereafter, NGS said and the same date, there is kind of this common perception that it could be in that 24 to 72-hour timeframe, that would be okay. There’s less to back that up, especially in Illinois when we look at Blue Cross Blue Shield of Illinois and GS, Medicare, and UHC. And all of those coming into play, which make up the vast majority of the payer marketplace.

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But today, I really want to talk to you about what is really the risks. Why is this critical? Well, the biggest thing that it centers around is memory, and remembering the details of a visit when you may have seen somewhere between 20 and 40 patients a day before. And so that’s really important, even 24 hours later, and why it’s critical to get those records done fast, quickly, right. Beyond the payer side of this, which is what we talked a lot about last week. But ethics is another piece of this pie. The reason why medical records are so important is really the primary reason is to be able to communicate with other providers, what’s happening in your practice, is that interoperability component. And so the ethics side of this is incredibly important, the ethics of getting it right, not forgetting the nuances of what may or may not have been said in a particular visit. And that’s why it’s important to get the documentation done very quickly, soon thereafter, or at the time of service.

Now, what are some other big keys? Well, there could be a lot of questions that are raised if you’re billing an insurance company, prior to the completion of your medical record. So if you send off a bill to an insurance company for services rendered that you haven’t documented yet, that could raise a lot of red flags in an audit in a recruitment timeframe, or if they’re just doing a record review, or for your potential opportunity for appeal, if there is a denial that could come into question as well. It’s something to be aware of. So we have, you know, the remembering that the overall purpose right is to communicate with other providers, the ethics side of this the billing prior to documentation.

But if the patient requests their medical records soon after they visit, and they’re not complete. Now, you know, with the Cures Act, this is even going to be more important. And if you haven’t seen our videos and read through our material on the Cures Act, I would strongly encourage you to go back and take a look at that. A lot of that was actually put out towards the beginning of 2021. Lots of information, we even have some webinars that are available for you to be able to check out and learn all about the Cures Act strongly encourage you to do that, especially since we’re coming up to one of the other deadlines for the Cures Act. But the reason why that’s important is because if they can electronically request the records, that means that they can electronically request those records as they’re walking out of your office, right? Ultimately, the longer those go delayed in their completion, it stretches out that time for you to be able to be in compliance with the Cures Act. And so as we move closer and closer to and it can happen any day where we start to see more and more or even hundreds of different Cures Act requests for medical records, as HHS begins to narrow that timeframe that allows you to to comply with records request to shorter and shorter timeframes when patients are requesting them on the right of access. And all of these come into play. And the more technologically savvy that your patients become, the more likely it is that they’re going to be requesting their medical records more often and more quickly after their visits.

So, we have you know, the ethics component of this the billing versus documentation completion component, we’ve got the Cures Act component, that all envelop in kind of an ongoing potential risk. And then, of course, the worst-case scenario when we start talking about malpractice scenarios, right? Of course, we always want what’s best for our patients. We want other providers that have the full amount of information that comes out of our practice for their health, but you also have the malpractice component. The worst possible thing would be is, is if your documentation wasn’t complete for many days following the service and I’ve heard some that are months, months after the service even and it’s that would be almost impossible to justify, in fact, it would be impossible to justify we being questioned by a plaintiff attorney. So, just know that there are inherent risks with not completing your documentation in the timeframes that are really allowable under many of the contracts that you most likely have signed and are required to adhere to. But at the very least buy Medicare, which is, you know, which is critical to get those done as soon as practicable.

Now, this is the other key, when they touch on all of this, one of the key phrases that they use is they say, in order to maintain an accurate medical record, and it goes back to what we talked about right at the beginning, which is that memory component. So there is an acknowledgment in the language that it just reminds us gently that we want to make sure that we maintain those accurate records for interoperability and for other providers, and also for payment and also protect us from malpractice. All these are risks and not completing your medical records in a timely fashion. get those done as close to that service date, even at the time of service, get as close as possible. And many of these risks go away. Hopefully, this helps you out and we’ll catch you next week.