Identify the Source of the Request Prior to responding to a records request, the clinic should identify the requesting party. Is it a payer or third-party? If so, the clinic would refer to contract obligations as well as state and federal rules. If the request is from the patient, the HIPAA Privacy Rule and Right…
Medical Record Addendums Despite best efforts and good intentions to complete perfect documentation at the time of service, errors and omissions can occur. When that happens, the situation has its own documentation requirements. Failure to properly amend a medical record can make it appear that someone was trying to falsify documentation, and that may be…
A Records Request: A Common Occurrence So, you check the office mailbox – a few EOBs, checks from patients, a menu from the local pizza place, and (sigh) a love note from an insurance company requesting records for a patient. Before panic sets in, understand that this is a common occurrence in the chiropractic profession….
When is a simple request for records not really a simple request for records? Almost every time. When a payer is asking for notes, whether for a current claim, or a retroactive review, it means something. It could be random, or it could be targeted and focused. Because you may not know, this is the…
Download Reference Documents Medicare publishes helpful documents and alerts to keep providers in the know about important topics. Included here are several documents that relate specifically to the rules of properly signing the medical record notes of patients. These tools relate to the elements of signatures, authentication, and attestation, should that be necessary. We’ve also…
Download Support Tool One of the most effective ways to ensure compliance is to perform periodic self-audits. These important self-checks are even a requirement of an office compliance program. By performing a retrospective review of a sampling of signed visits, you will establish a baseline of your current compliance with the signature guidelines. Download, review…