Get pid the importance of medical documentation

The importance of medical documentation

Medical documentation is necessary to claims being paid quickly

In today’s healthcare world you need to develop the necessary organizational controls to develop successful processes and procedures in order to stay compliant and financially healthy.  The key to excellent documentation is knowing what is required and what is not. Medical reimbursement comes only from what you have documented if something is not written down it did not happen.  This documentation is also a crucial form of communication. The importance of writing complete, concise, dated and timed documentation cannot be stressed enough. It is not only how you are reimbursed, but legal protection and critical communication.  In the event of a medical malpractice lawsuit the only tools you will have to work with is what has been recorded.

Insurance checklist complete concise date time

Accurate documentation begins with gathering patient information from the very first point of contact, and continually updating as the patient moves through the healthcare process.  Using verification tools will enable you the insight to see how you will be paid for services, and which services and procedures will require further approval from their healthcare provider.  Medical documentation is telling the patient story and applying the correct billable codes. Once services have been rendered it is the facilities responsibility to transcribe said services into billable charges. With clear and concise documentation, you can assign medical billing codes to the claim. These billable codes are the vehicle to revenue.  They are inflexible and must be followed to maintain a healthy bottom line.

Understanding the importance of good documentation is crucial to all aspects of the medical record.   Documentation is more than legal protection.  Medical records are a vital form of communication, and the importance of accurate and dated communication cannot be reiterated enough.

Communicate the treatment plan

Good documentation promotes continuity of care through clear communication with all that are involved in patient care.  This is a way to communicate your treatment plan to other providers for the patient.  This level of communication ensures the highest quality of care.

It’s a legal document from the medical provider

A medical record is a legal record of services rendered by the medical provider. Once written it is permanent.  In case of legal proceedings written documentation is called upon and reviewed to help support an argument either way.  So again clear, concise documentation is crucial to every step of the process.

It’s a document of medical services for the insurer

Medical documentation tells insurance providers what they are paying you for.  Each case is coded and translated into a cost for your practice.  Thorough documentation of all medical issues and treatments is therefore critical to your bottom line.

How do I get paid by insurance?

Your documentation is a process of taking all that is written and identifying it as a diagnosis’s, medical tests, treatments, and procedures for medical insurance. This information is then transcribed into standardized codes. These codes are what are then used to bill government and commercial payers for reimbursement of services rendered.

Information you need to get paid verification of benefits, assessment, date and time, treatment plan, procedure, diagnosis, billing codes

Medical billers are the professionals in charge of processing patient data, which would include treatment records, medical plans, and all related insurance information. Medical billers work to ensure that you, the healthcare provider is accurately and efficiently paid for the services performed.

A full understanding of medical insurance, the claims process, the appeals process, and the impact on your revenue cycle gives the medical billing professional the necessary knowledge to maximize revenue performance.  The financial health of your practice depends on the effectiveness and overall performance of the billing office.

Let’s take  look at your revenue cycle.  Revenue cycle management is an invaluable part of a successful healthcare organization.  Without a trustworthy and efficient billing company, you would be losing out on thousands of dollars in payer reimbursements, patient payments, that your practice depends on.

Understanding and executing an outstanding revenue cycle is an integral component of success.  We have all heard of location, location, location for successful real estate endeavors well for successful revenue cycle management it comes down to documentation, documentation, documentation.


SUD Billing Wellington, FL

Expect more from Us – A Utilization Rant

Working in the behavioral health revenue cycle management field behind the scenes performing utilization review and utilization management, advocating for those struggling with Substance Use Disorder and Mental Health Disorders has its challenges.

I chose to write this for its therapeutic value; although I do hope to get the attention of my colleagues to see if they are experiencing some of the same frustrations I do.  I have often thought of creating a supportive blog or platform where Utilization Review Professionals can share dissatisfactions, disappointments and exasperations over what are sometimes jaw dropping denials for patients struggling with potentially deadly issues.  It could also be a forum to discuss successes, as we know there are many of those as well.

Baffling are comments such as “we know this case, multiple treatment attempts- they will be fine in intensive outpatient” and “don’t expect a long length of stay, she is young she will bounce back. “   And my all-time outlandish award goes to “expect a step down at next review” – have you ever heard this and thought to yourself, “but I haven’t even provided the clinical for this review, how are you able to future trip my step down?”

These comments coupled with the denial letters received after a Peer Review make for further fodder. I do hope everyone is reading them. Personally, I can hardly recognize the clinical that was pulled out of conversations and used as rationale to deny a level of care. In most cases the information cited in the denial letter does not remotely represent the clinical information that was relayed to the doctor and it scarcely resembles any clinical documentation in the patient chart.

I often wonder if the physicians and clinicians at the insurance companies understand that comments such as “he is not homeless; he can sleep in his car” or “she is able to function day to day” after the patient attempted suicide the previous day, is homeless and also experiencing paranoid thoughts, could be considered discriminatory and stigma – possibly at its worst? That their oath to “do no harm” applies whether they are working in an office or working for an insurance company.

As I express my frustration, I would also like to convey that no matter what obstacle we face, an arrogant physician, a cranky care manager, a lax insurance payer, an indignant supervisor, we can’t give up on trying again and again and yet again to help those that are currently unable to help themselves. And further, we must always “Expect More” from those who can.

Although exhausted, we must pursue integrity. That takes stamina and the willingness to never give up. Our company tag line is “Expect More” – we never fall short of that; we give much more, that I can say with certainty.  We love what we do, we do what we love. We believe, that if you do not believe that a patient can get well and turn their life around then this is not work that you will be happy to do. I hope to see the day that the care managers of the insurance payers demonstrate the same belief.

At Integrity Billing, we celebrate victories such as overturned denials and appeals by ringing a bell every time those claims pay.  These are the types of things that make our day. Therefore, we are here.

Expect More.