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.


Medical Billing

The Most Frequent Medical Billing Errors That Companies Make

Medical billing errors are prevalent and can happen to any company. They often stem from a lack of understanding of the medical industry or insufficient staff who know how to code properly, especially in the medical billing companies. There are many ways to reduce these errors, but it is important to be proactive before your customers start complaining. At Integrity Billing, we specialize in billing and other healthcare management services. This blog post will discuss the most frequent medical billing errors companies make – some you might be making yourself without even realizing it.

1. Not understanding the medical industry.
This is one of the most common medical billing errors companies make. They may not understand what services are covered by insurance, how to code procedures properly, or what is considered a reimbursable expense. All of this can lead to mistakes when submitting claims and result in lost revenue for your company. However, outsourced medical billing services can help solve this problem.

2. Failure of verification of benefits for insurance.
Another common mistake companies make is failing to verify insurance coverage. Before submitting a claim, it is important to make sure that the patient’s insurance plan covers the service you are providing. If it’s not, you could be on the hook for the full cost of the procedure.

3. Not submitting claims on time.
This medical billing error can often be attributed to a lack of staffing or understanding of how the system works. When claims are not submitted on time, you run the risk of them being denied due to insufficient documentation. And if they are denied, you will have to resubmit them. However, an outsourced medical billing service provider can help solve this mistake.

4. Incorrect coding.
This is one of the most common medical billing errors and can lead to significant financial losses for your company. Incorrect coding can result from not having enough staff familiar with medical coding guidelines, or it could be due to human error. Either way, it is important to have a system to check coded claims before submitting them to ensure accuracy.

5. Not following up on denied claims.
If an insurance company denies a claim, it is important to follow up on it as soon as possible. Often, all you need to do is provide additional documentation, and the claim will be approved. However, if you don’t follow up on denied claims, you could end up losing money.

6. Filing duplicate claims.
This medical billing error often occurs when companies submit duplicate claims for already billed procedures. This can be a costly mistake, leading to claims being denied and additional administrative work.

7. Not verifying patient insurance eligibility.
It is important to verify that the patient is eligible for coverage before providing services. If you provide services to someone who is not covered by their insurance plan, you will be responsible for the full cost of the procedure. Therefore, verification of benefits is essential to ensure the eligibility of patients.

8. Failing to follow up on unpaid bills.
Often, bills go unpaid because patients forget or don’t have the money to pay them. Therefore, it is important to follow up on unpaid bills on time to get paid what you are owed.

These are just some of the most common errors that medical billing companies make. By being aware of these mistakes and taking the necessary steps to avoid them, you can ensure that your medical billing process is as accurate and efficient as possible. If you are looking for more tips on how to improve your medical billing process, contact Integrity Billing.