Encounter Documentation: A checklist for your practice

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How does your practice compare with this checklist?


Importance of Top-notch Encounter Documentation to Your Practice
If the process to create documentation is not efficient, complete, or accurate for that encounter, patient care, productivity, and profitability can all suffer.

Financial Uncertainty
When medical insurance claims are submitted with incorrect or incomplete information and coding, at best it will simply rejected, resulting in longer waits before reimbursement is received. When this happens frequently, a practice’s revenue flow can be unpredictable and uneven, plus there is the extra cost of time and staff needed to correct and resubmit the claims.

Insurance Audits
As if the problem of delayed revenue and the extra expense of resubmitting claims is not bad enough on its own, too many errors may trigger an audit from an insurance company, and the potential of needing to repay the company. The best way to prevent an audit is making sure the medical billing and coding is always done accurately and completely the first time, every time.

Impact on Patient Care
Incomplete and/or inaccurate billing doesn’t impact only the providers and their practice – it can have a negative impact on their patients’ ability to receive the proper treatment for medical services and treatments, including specialists or rehabilitative treatments. It can also impact their ability to be reimbursed for their expenses.

Fraud Investigations and Legal Actions
Audits from insurance companies can be stressful, but nothing compared to fraud investigations and legal actions. Even when errors are simply errors – not intentional – investigations may still be initiated when there is even a suspicion of fraud. A fraud investigation, and the possible legal action as a result, can severely disrupt a practice and put everyone’s livelihood in jeopardy.

How to Avoid Problems
The first line of defense against delayed revenue, insurance audits, fraud investigations, and legal actions is to have experienced, properly trained, and quality professionals in place. Regular training of all staff on billing and coding regulations and practices as well as solid policies and procedures for the practice is essential.


If you don’t have time to do it right the first time, how will you have time to fix it?
Scribe’s documentation solutions are designed to let you quickly and efficiently document your patient encounters, simply, easily the first time, every time.

Are you ready to improve your patient encounters? Click the button below to get started.