Introduction to Health Insurance

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1 Chapter 2 PART 2 of 2 Introduction to Health Insurance Copyright 2013 Delmar, Cengage Learning. ALL RIGHTS RESERVED. 1

2 Healthcare Documentation Documentation is the systematic, logical, and consistent recording of a patient s health status, history, examinations, tests results of treatments, and observations in chronological order in a patient medical record. Healthcare Providers are responsible for documenting and authenticating legible, complete and timely patient records in accordance with federal regulations (e.g., Medicare Conditions of Participation) and, accrediting agency standards (e.g., The Joint Commission). 2

3 Healthcare Documentation A patient record (or medical record) documents healthcare services provided to a patient. Records include Patient demographic data Documentation to support diagnoses and justify treatment provided Results of treatment provided 3

4 Medical Documentation The primary purpose of the medical record is the Continuity of Care, which involves documenting patient care services so that others who treat the patient have a source of information to assist with additional care and treatment. 4

5 Medical Documentation Secondary Purpose of the record, not related directly to patient care & include: Evaluating the quality of patient care. Providing data for use in clinical research, epidemiology studies, education, public policy making, facilities planning, and healthcare statistics. Providing information to third-party payers for reimbursement. Serving the medico-legal interests of the patient, facility, and providers of care. 5

6 Medical Documentation Documentation includes dictated, transcribed, typed or handwritten, and computer-generated notes and reports recorded in the patient s records by a healthcare professional. It must be dated and authenticated (with a legible signature or electronic authentication). 6

7 Medical Documentation In a teaching hospital, documentation must identify: what service was furnished, how the teaching physician participated in providing the service, and whether the teaching physician was physically present when care was provided. 7

8 Medical Documentation - cont Documentation in the patient record serves as the basis for coding and must support the medical necessity. The patient s diagnosis must justify diagnostic and/or therapeutic procedures or services provided, and requires providers to document services/supplies that are: Proper and needed for the diagnosis or treatment of a medical condition 8

9 Medical Documentation - Cont Physicians must document services/supplies that are: Cont Provided for the diagnosis, direct care, and treatment of a medical condition Consistent with standards of good medical practice in the local area Not mainly for the convenience of the physician or healthcare facility 9

10 Medical Documentation - cont If it wasn t documented, it wasn t done. If a provider performs a service but does not document it, the patient (or third-party payer) can refuse to pay for that service, resulting in loss in revenue for the provider. Missing documentation can be a problem if the record is used in a court of law. 10

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12 Problem-Oriented Record (POR) Document Formats are used to organize patients medical records. Systematic method of documentation consists of four components. Database Problem list Initial plan Progress notes 12

13 Problem-Oriented Database Database format of information collected on each patient are: Chief complaint Present conditions and diagnoses Social data Past, personal, medical, and social history Review of systems Physical examination Baseline laboratory data 13

14 Problem-Oriented Record The initial POR plan contains the strategy for managing patient care, as well as any actions taken to investigate the patient s condition and to treat and educate. The initial plan of treatment consists of three categories: Diagnostic/management plans Therapeutic plans Patient education plans 14

15 Problem-Oriented Record Progress Notes Progress Notes for each Problem are in the SOAP Format beginning with the Problem and then four points: Subjective & Objective Assessment & Plan 15

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19 Electronic Health Record EHRS (Electronic Health Record System) is a networked of computers that use practice management software that is capable of compiling electronic health records. It uses either free-text or built-in templates to help structure documentation through a process of answering a series of questions and entering data. 19

20 Electronic Health Record The EHRS (Electronic Health Record System) is also a collection of medical information about the centralized electronic system. The system receives, stores, transmits, retrieves, and links data for giving health care services from many information systems, such as laboratory test results, radiology reports, x-ray images, pathology reports, and financial documentations. 20

21 Electronic Health Record (cont.) Provides access to complete and accurate patient health problems, status, and treatment data. Allows access to evidence-based decision support tools (e.g., drug interaction alerts) that assist providers with decision making. 21

22 Electronic Health Record (cont.) Automates and streamlines a provider s workflow, ensuring that all clinical information is communicated. Prevents delays in healthcare response that result in gaps in care (e.g., automated prescription renewal notices). 22

23 Electronic Health Record (cont.) Supports the collection of data for uses other than clinical care (e.g., billing, outcome reporting, public health disease surveillance/reporting, and quality management). 23

24 Electronic Medical Record Provides a more narrow focus because it is the patient record created for a single medical practice using a computer, keyboard, mouse, optical pen device, voice recognition system, scanner, and/or touch screen. 24

25 Electronic Medical Record (cont.) Includes a patient s medication lists, problem lists, clinical notes, and other documentation. Allows providers to prescribe medications and order and view results of ancillary tests (e.g., laboratory, radiology). Alerts the provider about drug interactions, abnormal ancillary testing results, and when ancillary tests are needed. 25

26 Total Practice Management Software Used to generate the EMR, automating the medical practice functions, such as: Registering patients Scheduling appointments Generating insurance claims and patient statements Processing payments from patient and third-party payers Producing administrative and clinical reports 26

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28 Advantages of Electronic Medical Records (EMR): immediate access to health information computerized physician order management clinical decision support automated alerts and reminders electronic communication and connectivity patient support administration and reporting error reduction 28

29 Disadvantages of Electronic Medical Records: cost lack of technical support privacy and security concerns 29

30 Electronic Health Record System VS Electronic Medical Record EHRS (Electronic Health Record System) is all patient medical information from multiple sources including all components of the EMR (Electronic Medical Record) EMR (Electronic Medical Record) is an individual physician s electronic medical record for the patient including medical history, allergies, and appointment information. 30

31 Physician Incentive Payments for Meaningful EHR Users Medicare provides annual incentives to physicians and group practices for being meaningful EHR user. Meaningful EHR is defined as: Physicians who demonstrate that certified EHR technology is used for the purposes of electronic prescribing, electronic exchange of health information in accordance with law and health information technology standards, and submission of information on clinical quality measures. 31

32 Physician Incentive Payments for Meaningful EHR Users Hospitals that demonstrate that certified EHR technology is connected in a manner that provides for the electronic exchange of health information to improve the quality of health care and that certified EHR technology is used to submit information on clinical quality measures. 32

33 Physician Incentive Payments for Meaningful EHR Users Physicians will receive a decrease Medicare Part B payments beginning in 2015 if they were eligible, but did not implement an electronic health record (EHR). After 2017 Medicare Part B payments may be reduced an additional 1% for each year in which less than 75% of physicians eligible to be meaningful HER users are using electronic health records. The Maximum Medicare Part B payment decrease is 5% DHHS may exempt physicians for 5 years, due to hardship. 33

34 Health Information Technology HealthIT Health Information Technology (health IT) makes it possible for health care providers to better manage patient care through secure use and sharing of health information. Health IT includes the use of electronic health records (EHRs) instead of paper medical records to maintain people's health information. 34

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