Clinical and billing documentation are only second to patients as the lifeblood of your practice. Needless to say, keeping them accurate, up-to-date and easily accessible is essential as documentation mistakes can increase your claim rejection rates, wreak havoc on patient care, increase your risk of an audit and more. Practices who are using outdated software or haven’t yet made the shift to paperless, are invariably losing time and money with these common (and costly) mistakes.
Here’s how to spot your documentation gaps and fix them.
Your documentation is still handwritten
Handwritten patient notes are notoriously hard to read, not just by your admin staff, but by pharmacists and other treating medical professionals. Replacing illegible notes with digital notes makes sense for both your practice’s finances and your patients’ safety. For example, to avoid billing mistakes that result in either inaccurate claims and/or loss of income, use a billing system that enables you to capture your clinical notes electronically and then converts and sends them to your staff as billing instructions. By doing this, there are no misinterpretations of what the patient was treated for, plus by using billing templates, you can ensure all the procedures and consumables are included so you don’t lose out on income.
Your documentation isn’t well organised
Fragmented and disorganised clinical and billing documentation often means waste – of time, money and resources. Losing or misplacing lab test results, for example, will result in ordering more tests which is both unnecessary and drives the cost of care up. It also doesn’t help when you’re under time pressure and need access to clear, organised information to make the best care decisions.
By using an electronic medical record, patient information is stored in an organised, easy-to-recall way. For example, patient visits are stored in chronological order with search functionality for easy recall of past treatments and medications. Important information such as allergies, medical aid information and clinical metrics are displayed in a summary view so you can easily see what you need to know about the patient in a glance.
Your documentation isn’t safely & securely stored
If you’re still using paper files, it’s likely that they’re being kept under lock and key, but is that enough? Physical files can be exposed to fires, theft, flooding, loss, damage and more. Storing files in the cloud removes these risks and makes your patient files available to authorised users from any device that has an internet connection. That increases efficiency significantly but most importantly, your clinical and billing documentation is safe and secure from data breaches or any other unauthorised access.
Your documentation does not contain structured data
Structured data is important to allow you to aggregate your practice data. Using only ‘free text’ or ‘clinical narrative’ means that you can’t easily perform an analysis of your data to monitor your practice’s performance from a productivity, billing or clinical perspective.
Trends in your practice are enormously useful to help you understand how best to care for patients, what services to offer, who the most prominent insurers are within your patient population and much more. If your data is stored as handwritten notes, there’s no way to access or analyse that data to give you any useable information. This can be costly, but it can also be rectified. By using a digital system that allows you to capture, store and revisit clinical and billing information, you can generate reports to show you the trends in not only your practice, but your patient’s health and allow you to make data-driven decisions about the running of your business.
Your documentation is not streamlined
Many practices continue to use separate clinical (whether digital or paper) and billing systems. This is probably one of the biggest mistakes practices are making. Not only are you having to spend (waste) precious time capturing duplicate data between two systems that can’t ‘talk’ to each other, but the possibility of finger or interpretation error is also geater. What results is entry errors, inaccuracy and increased chance of having your claims rejected. In short, expensive.
Using one system to capture relevant patient and treatment information that then automates the process of generating billing information to your billing system can save time, money and frustration.
Healthbridge’s Clinical & Billing solution affords practices accurate and complete billing, based on the templates you’ve chosen and the patient information you’ve captured. After entering your diagnosis, applicable procedures, consumables and medicines you’ll be asked to confirm your submission. That information is then used to generate an invoice, quickly and efficiently. Using one system to capture and use clinical and billing documentation eliminates the need to make additional notes and avoids anything being lost in translation.
As you will see from the above list, these common mistakes are entirely avoidable. If you’re concerned that your practice is losing money or not operating optimally because of these clinical & billing documentation mistakes, get in touch with Healthbridge to find out how a single integrated digital system can be the best medicine for your practice. Click here to request a call back and a Business Consultant will be in touch.