"Practices need to vastly improve data accuracy in records, attorney says"

October 17, 2019

News

The processes of medical recordkeeping continue to change, as regulators more frequently set new requirements, and many healthcare organizations struggle to keep up with the changes.

But the big problem is that too many hospitals and practices still haven’t managed the basics of collecting and reporting data for regulators and attorneys, Isabelle Bebit-Kilinyak, a corporate attorney in the McDonald Hopkins law firm in Cleveland, noted during an educational session at the Medical Group Management Association’s annual conference.

“We still see too many errors in data,” she asserted. “Signatures cannot be read, required information is omitted, and relevant information also is omitted. Who is keeping track of physical signature logs?”

Too often, providers are not ensuring that patients and families understand basic necessities, such as when a patient needs to take medication. These mistakes could end up resulting a lawsuit.

Many providers do not know that if the medical record is a combination of paper and the electronic health record, and that information is not scanned into the EHR, then all of the documentation has be given on paper. Further, providers are releasing information prematurely that should have first been assessed first under legal review.

Click here to read the full article.

Over the past 24 months, the U.S. Department of Health and Human Services Office for Civil Rights has brought notable enforcement efforts against several non-profit covered entities and business associates, resulting in instances of six and seven-figure penalties against providers across the county for incidents involving breaches of protected health information.

A new amendment to New York state law, which would have required all healthcare providers to obtain separate consents from patients for treatment and payment is on hold until further guidance is released, according to the New York Department of Health.

On November 1, 2024, the Centers for Medicare & Medicaid Services issued the Medicare Physician Fee Schedule 2025 final rule, which establishes new advanced primary care management billing codes that will expand opportunities for physician practices, federally qualified health centers, rural health clinics and other health care providers to get paid for services provided by clinical staff under the direction of a physician, nurse practitioner or physician assistant beginning January 1, 2025.

"Practices need to vastly improve data accuracy in records, attorney says"

Related Services

You may also be interested in