Health care documentation is critical to quality patient care, as well as risk management for health care facilities and individual providers. This program will review state and federal law requirements concerning documentation of patient care. The program will also discuss the importance of accurate, timely, and comprehensive patient care documentation and highlight the legal risks and exposures of poor documentation.
Topics to be discussed:
- What to consider when contemplating automation of medical records
- Implementing electronic medical records case study
- Implementation of the compliance plan and committee
- Interaction between insufficient or misleading documentation
- Overpayment disputes
- False claims/fraud litigation
- Auditing and documentation of medical records
- Information technology/practice management issues
- The attendee will be able to discuss current trends.
- The attendee will be able to review state and federal law requirements.
- The attendee will be able to identify legal risks and exposure of poor documentation.
8:30 a.m. - 10:40 a.m. (Break 9:30 a.m. - 9:40 a.m.)
I. What To Consider When Contemplating Automation Of Medical Records The Many Choices
Beyond And Before System Selection
D. Automation Of Redundant Processes
E. Case Study
10:40 a.m. - 11:40 a.m.
II. Implementing Electronic Medical Records Case Study Dealing With Records Once They
B. Key Implementation Strategies
C. On-Going Maintenance And Considerations
D. Lessons Learned
11:40 a.m. - 12:40 p.m.
Lunch (On Your Own)
12:40 p.m. - 1:40 p.m.
III. Implementation Of Compliance
A. Development Of A Compliance Plan
B. Establishing The New Culture
C. Launching, Refining And Maintaining The Compliance Committee
1:40 p.m. - 2:40 p.m.
IV. Interaction Between Insufficient Or Misleading Documentation
A. Establishing Medical Necessity
B. Documenting The Level Of Service Provided
C. Use Of External Evidence Or Working Around Payors Policy 'If It Isn't Written Down, It Wasn't Done'
V. Overpayment Disputes
A. What To Do When You Get The Request For Charts
B. What To Do When You Get The Refund Demand Letter
C. Appeal Rights Under Medicare, Managed Care, And Private Insurance
D. Limits On Use Of Extrapolation
E. Voluntary Disclosure To Carrier, Enforcement Agencies
VI. False Claims/Fraud Litigation
A. Qui Tam 'Whistleblower' Actions Or How To Inform On Your Doctor For Fun And Profit
B. What Is A 'Knowing' Submission Of A 'False Claim' Or Statement? What Is Action In 'Deliberate Ignorance' Or 'Reckless Disregard' Of Truth Or Falsity
C. Defense Strategies And Use Of Expert Testimony
D. Settlements And Corporate Integrity Agreements
2:40 p.m. - 2:50 p.m.
2:50 p.m. - 3:40 p.m.
VII. Auditing And Documentation Of Medical Records
A. Overview Of Negligence And Medical Malpractice
B. Medical Record Review
C. Audit Of Charts Compliance, Comparison, Coding
3:40 p.m. - 4:30 p.m.
VIII. Information Technology/Practice Management Issues
A. Practice Management Systems
1. What To Look For
B. Managing Billing Cycles Can Boost Revenue