It’s All In The Form

Originally published by Kennedy, Attorneys & Counselors at Law.

Some governmental agencies have their own forms that must be completed at some point in  time. Other forms are left to the provider. Each provider type typically has leeway in some of their forms, whether the provider chooses to use a nationally recognized form, or to make one up to fit the need.

If the form is not relegated by an agency, you should make certain the form you use adequately  applies to your situation. Within the past 8 months or so, we have experienced state licensing boards (three different ones) lambasting the practitioner for not properly completing a form. Even if not all of the blanks are necessary all of the time or if your staff leaves a blank empty, it may be determined the blank was skipped rather than not applicable. That omission may result in a sanction.

If the form is relegated by an agency, you should make certain the form is correctly filled out.  For any sections that do not apply, the staff member should mark them as such. This way, the reviewer, whether with a Medicare, Medicaid, or insurance contractor or a licensing board, will know the section did not apply to the beneficiary/recipient and a full picture of the state of the patient can be known from the form itself. Further, if the form is mainly boxes to be checked, make certain there is room for comment, and then make certain the comments are made as needed.

If your records are electronic (which most providers’ records are), does a blank form come up for each client to be noted?  If not, how can you be certain that each blank that needed changing from the last note was changed? You can’t. A recent Board of Nurses review of home health records found the nurse had been in 2 places at the same time on a variety of days. What occurred was the prior home health visit note had been used as a template and sometimes the nurse forgot to change the time of the visit. When viewed as a group, the notes indicated the nurse had been in 2 different places at the same time on the same day. Of course he wasn’t, but the records showed that he was. While the nurse was a talented man, the Board of Nursing sanctioned him for making incorrect records.

In summary, licensing boards and Medicare and Medicaid Contractors all perform a record and document review prior to determining sanctions or overpayments. Make sure your forms give enough information for the reviewer to know what is going on with the patient. The time you take to properly complete a form is time well spent.

Curated by Texas Bar Today. Follow us on Twitter @texasbartoday.

from Texas Bar Today http://ift.tt/1XpULsL
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