Learning Objectives
Your medical records are reviewed and judged every day by third parties, including other healthcare providers, patients, internal compliance departments, third-party payors, federal and state regulators (DPH, DCP, DSS, DEA, CMS, HHS), and law enforcement. Some parties are seeking to understand the care provided to a particular patient and others are evaluating the records for trends that could demonstrate aberrant prescription practices, findings of lack of medical necessity, billing fraud, and professional misconduct. The care you take in creating, maintaining, and retaining these records can be the difference between a brief inquiry and a protracted investigation that could lead to licensure restrictions or criminal or civil penalties.
Whether you practice in a small group, a multi-specialty super group, or in a hospital system, the completeness of your medical records is most likely being evaluated, both internally and externally. The purpose of this program is to provide an overview of how you can prepare a medical record that will protect you and your practice and will cover a variety of topics, including:
- What information third parties routinely look for?
- What information do physicians forget to include that could later be problematic?
- How EMRs provide payors and regulators with additional avenues of attack?
- What is currently required for telemedicine records?
- How to address unique circumstances?
- How can your medical record protect you when you have a non-compliant or when the physician-patient relationship is terminated?
- What you need to consider when emailing or texting patients?
- How to protect yourself as you wind down the practice of medicine?
