Efforts within the insurance industry to reduce claim expenditures, crack down on fraud and abuse, and reduce the rate of payment errors should persuade chiropractors who are experiencing problems getting reimbursed to improve their documentation. In disputes relating to reimbursement or malpractice, the patient record is the most important evidence doctors have in their defense.
Several years ago, the American Chiropractic Association (ACA) assembled a group of insurance representatives for a frank discussion of issues. The insurers agreed unanimously that chiropractors needed to provide better documentation of their services. Legibility and the use of non-standard abbreviations are major issues in many records. Documentation must be understood by a third party. Being sloppy or taking shortcuts will not serve the doctor's interest in the end-or help the patient get approved for future visits.
Any claim handler will likely tell you that notes that are handwritten using abbreviations are the most despised. Notes that take an inordinate amount of time to try to decipher, lead to delays in the payment process. Failing to provide documentation of a patient's progress frustrates reviewers because it leaves them with an incomplete picture of the patient's treatment and condition.
Creating good documentation is also a legal obligation. Statutes in every state specify what type of records a doctor must create and maintain. Those who fail to comply may be reprimanded or even lose their license to practice.
SOAPe Platinum can help to ensure that your notes and reports meet industry standards, and help to protect you from liability.
