Ignorance is no excuse. Over the last few months, like me, I’m sure you’ve seen headlines and read articles about the federal crackdown on Medicare and Medicaid fraud. Millions of dollars have been identified as fraudulently paid for services either not rendered or with limited justification. I acknowledge that there are unscrupulous practitioners and providers out there who should be identified, indicted, convicted, and sentenced to the fullest extent the law allows. However, while I don’t have the numbers, I wonder to what extend “fraud” was committed by those who unwittingly engage in poor billing practices, such as miscoding and/or absence of support documentation for procedures provided. The old adage, that if you didn’t document it, it didn’t happen, may put providers and practitioners at risk of investigation and indictment with all the attendant negative results, such as loss of reputation, decline in confidence, and possibly business failure.
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A Major Health Care IT Paradigm Shift
“Best Practices” in the old days – paper pushing.
Historically, health care in general and long term care specifically, has been intensively paper based - forms, spindles, chart tables, racks, and binders. Documentation was (and still is) the name of the game and pushing paper was the only way. Even regulatory enforcement surveys were based on paper compliance with bedside visits to verify the documentation. Paper-based documentation consumed a lot of trees and filled a lot of storage files and storage units.