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.


Utilization Management Palm Springs, FL| Utilization Management Service

The Role of Utilization Management in a Healthcare Facility

When you need to ensure your health care services are cost-efficient and compliant, you must clearly understand the process of utilization management (UM). Many changes have been made in the healthcare industry, but UM should still be an essential part of your management program. This complex process will improve the quality of your services, the health of your patients, the satisfaction of your employees, and reduce costs.

What Is UM?

As you may already know, UM is a complex but necessary process that ensures patients receive the best possible care, without unnecessary tests and costs. A good team can evaluate the value of the treatment each patient receives, lower costs, reduce denials, and improve patient care. Having the right team on your side can also ensure compliance and increase efficiency among your staff. A strong team is exactly what you will get when you contact Integrity Billing. We understand the true nature of your operation. Our background includes behavioral health, medicine, surgery, and chiropractic care.

In greater detail, here are just a few ways our team can help yours.

Reduce Healthcare Costs

With the increasing rise of healthcare costs, teams are looking for ways to save money without sacrificing patient care. Lowering costs can come in multiple forms. Our management program is thorough when it comes to saving your medical organization money. We will review all claims and services that patients receive to ensure they are medically necessary, which will also reduce claim denials.

Better Adherence to Regulations

As a healthcare organization, your team must adhere to multiple regulations. A comprehensive utilization review plan will help you stay compliant with all regulations. A utilization review plan is a requirement by the Centers for Medicare and Medicaid Services (CMS), so if your organization participates in these programs, we will make sure your review plan meets all the necessary requirements.

Reduce Denials

A UM staff is essential for reducing the number of denied claims in several ways. They can:

  • Review medical cases and provide modifications when necessary
  • Ensure proper documentation to prevent missing or incomplete information
  • Evaluate and approve treatments that will receive fewer denied claims

Improve Patient Care

No patient wants to pay for unnecessary treatment or treatment that simply does not work. The UM team is critical in this aspect, as well, because they review the best possible results of individual treatments and whether they are the best option for the patient. As any professional in the healthcare industry knows, finding the right treatment for their patient will yield positive patient results.

Comprehensive UM Programs Matter

There are a few types of UM and each one is necessary for healthcare quality. Reviewing treatments for effectiveness is an important goal of an efficient UM team. For this and many other reasons, a properly managed team can benefit the patient, the medical staff, and the insurance provider.

Contact Integrity Billing

Our goal is to address the needs of medical facilities so you and your staff can focus on patient care. We are committed to protecting your business revenue by working beyond traditional billing throughout the billing and collections process. Depend on us for better revenue management. Contact Integrity Billing or call (866) 413-1559.