In healthcare organizations across the country, closing medical charts is a complex and can be a political issue. Many organizations understand that timely reconciliation of medical charts is multifaceted and implicates quality, reimbursement, and compliance. Without a standardized policy influencing physicians and other providers to appropriately manage the opening and closing of medical charts, an organization is placing itself in a position of substantial risk in multiple areas. This article highlights how organizations can mitigate this risk in developing a standardized policy influenced by compensation penalties.
Understanding Risk
Malpractice
The medical record is the central documentation point as it relates to any malpractice claim. Without an accurate record, individual providers run the risk of lack of documentation or incomplete documentation in relation to their care. Many providers ignore the fact that a delay in documentation raises substantial risk around the integrity of the record.
For example, the fact that an individual completed their medical record 15 or even 30 days after they provided the care present substantial risk that the record would be challenged in a malpractice lawsuit. The question would not be whether a record exists but whether the provider was actually able to recall the care provided. The bottom line is that delayed documentation creates substantial questions in relation to the accuracy of the record.
Medicare Regulations
Under federal health care programs, the precursor to payment is medical necessity of the service. A part of medical necessity is proper documentation as it relates to the reasons for the care and services. Further, the regulations require that organizations have a process in place in which providers document in a timely manner. Specifically, the following is noted by CMS “Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.”
In the event an organization does not have a process in place in which individuals are meeting this standard, it is possible that certain violations could occur under the Medicare regulations. This could include anything from denial of claims to enforcement regarding inappropriate billing.
Quality of Care
The medical record helps providers ensure a high level of care is being provided and coordinated. By delaying this process it is possible that information is missed, other providers do not have access to recent records, or the information is simply not available. The bottom line is that there is a significant quality issue and risk if delayed.
Setting the Rules
At a minimum, organizations should create a maximum number of days in which a chart can be open. No more than 14 days should be utilized. In addition, creating a penalty for charts beyond the open period is necessary. This is important for two reasons. First, without some sort of penalty, most individuals will continue to abuse the system. Second, closing charts is about more than billing, it is about fulfilling a basic requirement of the job.
Organizations that seek to create a policy should focus on a two fold penalty. The maximum of 14 days should be based around five or ten charts above that number. This allows some flexibility while at the same time limiting the possibility of high numbers. If an individual has six charts open past 14 days, any bonus eligibility should be forfeited. Or, as an initial penalty, it could be a discussion with a CMO. If that is the case then a financial penalty should occur at day 21, seven days later.
By implementing a clear and concise policy, influenced by your compensation model, you can more easily ensure high quality care within your organization.
