Author Topic: Paper work/Files  (Read 3271 times)

dfranklin

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Paper work/Files
« on: May 30, 2009, 04:55:08 AM »
Are we required to keep all of our records that we get from providers for billing (ie daysheets, EOB's, Patient Intake forms etc)?  Or can we shred them or return copies back to the doctors office to handle?

If we have to keep records on file what is the best way to organize them?  Would we need to file it by patient within an individual provider.  Or just by providers and group items within each provider like (daysheets, EOB's, and all patient intakes etc)?

Thanks!

Pay_My_Claims

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Re: Paper work/Files
« Reply #1 on: May 30, 2009, 07:06:21 AM »
required.....don't think so, should you?? Yes!! I would keep on file anything you deem necessary in case of an audit. EOB's reports etc...invest in a scanner and data-sticks. I wouldn't do a paper file. Paper accumulates. Technology is fantastic.

PMRNC

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Re: Paper work/Files
« Reply #2 on: May 30, 2009, 08:22:23 AM »
Billing companies must retain their records/source documents for the same time period; 7 years (Federal) as providers. You have to search for your state laws too because if your state's record retention rule is longer you go by that.

As for filing, I was always taught the medical record and billing record should remain separate, the logic for that is if there is an audit the carrier is getting only the information they need pertaining to the audit and privacy is not violated unnecessarily. I filed two ways, first by patient with all EOB's and superbills, later on when I had my providers go to daysheets I filed all daysheets by date and then EOB's were filed by date posted so I could easily find the EOB.  Today a lot of companies are going paperless and there are various companies specializing in that.
Linda Walker
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Pay_My_Claims

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Re: Paper work/Files
« Reply #3 on: May 30, 2009, 09:10:13 AM »
7 years..isn't that tax records??

PMRNC

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Re: Paper work/Files
« Reply #4 on: May 30, 2009, 09:31:39 AM »
NO NO NO Record Retention Laws are also for Medical Records.
Type in "Federal Medical Record Retention Laws"

Billing companies are treated the same as a provider...they have to keep source documents (anything given to them from the provider for the purpose of billing) for 7 years OR the length of time if their state's law is higher. NJ for example is 10 years.

This is a biggie.. should be in your compliance manual as well as stated in your contracts so that later on the provider is not saying to you "I want my stuff back!"  Absolutely do NOT turn them over.
Linda Walker
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Pay_My_Claims

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Re: Paper work/Files
« Reply #5 on: May 30, 2009, 01:02:53 PM »
Ok, I have to look more into this because I believe me and the poster are speaking of "non clinical" medical records. (which really shouldn't be called that). I read a couple of articles and NC has a 5 year record keeping law, and then there are federal and also "suggested" length of time from the AHIMA http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_012545.hcsp?dDocName=bok1_012545

I know we keep our records I believe at the DME company I work for at least 5 years, because our grave has charts to 2000, so that means they are compliant. We are doing EMR now so we will get rid of the graveyard soon. Our EOB's etc are not kept for that period of time unless a copy is put in the chart. I haven't seen records past 2 years for EOB's in any office that I worked in. I just started in March on my own, so I know I am already compliant :-), but I will research into it.

Thanks for the info.

PMRNC

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Re: Paper work/Files
« Reply #6 on: May 31, 2009, 09:59:18 AM »
Here's a jump:
Quote
On December 22, 2006, Public Acts 481 and 482 of 2006 became effective. Act 481 imposes obligations on individual providers and healthcare facilities and entities relating to the maintenance, retention and disposal of medical records, while Act 482 affects the disclosure of certain patient health information in response to Freedom of Information Act requests. These new laws may require individual providers, healthcare entities and facilities to review and revise their medical record retention and disposal policies and procedures to conform with the new requirements.

This is the update. It's always been required that medical practices retain records, each state also has their own.  In our subscriber area we have a whole section on record retention. For Noth Carolina, Its one of those states not so cut/dry or black/white:
They actually have an 11 year statute for facilities/hospitals, hospice..but no "office" record policy which then places the minimum requirement to the federal level of 7 years.

It's important to note that billing records are a part of the medical record, PHI, and DRS (Designated Record Set)
 
Linda Walker
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PMRNC

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Re: Paper work/Files
« Reply #7 on: May 31, 2009, 10:22:36 AM »
It's also important to note that the retention of records should be included in your compliance plan as well as policies and procedures.. for both the billing company and the medical office so there is a chain of consistency. If you are servicing clients in various states you need only document your retention period for the federal level unless state law supersedes.
Linda Walker
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Pay_My_Claims

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Re: Paper work/Files
« Reply #8 on: May 31, 2009, 01:45:02 PM »
Again, I will research that, because entity to me doesn't necessarily mean me as a billing service. I don't provide health care. I also really don't have any medical records. I think that may be the controversy. It's not a dispute of your information, because I can't say you are wrong, when I really don't know. I just read an article on who "owns" the medical records, the provider or the billing agent. I have seen several post about providers asking for their medical records back from billing companies, and not to relinquish them You are correct when you say it's not clear, because it is up to interpretation. I want to see something that states MEDICAL BILLING COMPANIES, must maintain medical records (including eob's, patient demographics, clinical information etc) up to xxx amount of time. I don't want it to be so evasive. If I can't find that, I may still not believe I have to do it, but because I don't like prison...I would retain the records!!!

Pay_My_Claims

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Re: Paper work/Files
« Reply #9 on: May 31, 2009, 05:35:07 PM »
*Linda*
Here is the article that I was reading. I know it's not law, but it is very interesting. It also relates to what I was speaking on as far as medical records. I don't consider EOB's etc part of a patient's medical record.

http://www.mpcg.org/news_det.phtml?id=5


PMRNC

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Re: Paper work/Files
« Reply #10 on: June 01, 2009, 06:43:14 AM »
First, EOB's Are considered to be a part of the DRS as well as PHI, under federal regulations. That's clear.
Second I guess it's import to say the federal regulations verbiage does cover "agencies" in regards to collectively calling them providers specifically ACT 481:

"Act 481 affects health facilities, agencies and healthcare professionals and imposes new laws relating to medical records. Imposed are requirements regarding patient notification, and the maintenance and disposal of medical records.

Regarding record retention and maintenance, healthcare providers, entities and agencies (collectively referred to as "Provider") are now required to:

(a) maintain a patient record for each individual to whom medical services were provided;

(b) maintain the records for a minimum of 7 years from the date of service unless federal or state law or medical practice standards require a longer retention period "

Second, you have to remember if you are a billing company you are either a covered entity or a business associate.

As for who owns.. and a doctor asking for his records back.. he shouldn't need them back if he followed the law himself and had his copies.. ie; his/her's source documents.   Your source documents are anything received by the office in order to do your job and they become your property by law as record of the work you did. If there is an audit of the practice, YOUR records will be evidence/records used to perform the audit thereby the liability of a billing company, essentially by saying you don't have to retain your source documents you are saying that an auditor will be directed to go to the provider for the records when it was your company that did the billing? That won't go over too well.

Finally, there is the legal definition of the LEGAL.Record 

Definition of the Legal Health Record

"The legal health record is generated at or for a healthcare organization as its business record and is the record that will be disclosed upon request. It does not affect the discoverability of other information held by the organization. The custodian of the legal health record is the health information manager in collaboration with information technology personnel. HIM professionals oversee the operational functions related to collecting, protecting, and archiving the legal health record, while information technology staff manage the technical infrastructure of the electronic health record.

The legal health record is the documentation of healthcare services provided to an individual during any aspect of healthcare delivery in any type of healthcare organization. It is consumer- or patient-centric. The legal health record contains individually identifiable data, (payment or treatment), stored on any medium, and collected and directly used in documenting healthcare or health status.

Legal health records must meet accepted standards as defined by applicable Centers for Medicare and Medicaid Services Conditions of Participation, federal regulations, state laws, and standards of accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations, as well as the policies of the healthcare provider.

Legal health records are records of care in any health-related setting used by healthcare professionals while providing patient care service or for administrative, business, or payment purposes. Some types of documentation that comprise the legal health record may physically exist in separate and multiple paper-based or electronic or computer-based databases.  "



Of course, if questioning, it's best to talk to your attorney, again keep in mind your "formal" and legal "status" as a billing company.
Linda Walker
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Alice Scott

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Re: Paper work/Files
« Reply #11 on: June 01, 2009, 10:38:44 AM »
Thanks Linda for that great explanation.  I'm sure it will be helpful and eye opening to many.
Alice
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dfranklin

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Re: Paper work/Files
« Reply #12 on: June 01, 2009, 12:34:47 PM »
WOW!  Definately opened my eyes!  I have been keeping my files but it looks like I better get a better grasp of the laws and guidelines on these things..I had no idea!

Thanks again!

PMRNC

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Re: Paper work/Files
« Reply #13 on: June 02, 2009, 06:34:25 AM »
Record retention and ownership rights is actually 7 pages long in my compliance plan. The medical record is no longer just the medical record, with the development of HIPAA it then became the "legal record" / PHI and of course your DSR for your billing company. You could have a client terminate and 3 years later be subject to an audit which means YOUR records can and would be audited as well.

Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com