Documentation, Documentation, Documentation

Good documentation is a key element for EMS providers and billing companies alike. Good documentation is especially important when it comes to illustrating medical necessity – this is how we all get reimbursements and remain compliant.

The current fraud and abuse landscape is alarming and the government, rightfully so, has targeted the EMS industry for audit. Audits are being conducted more and more and it is vital that we get our documentation correct. If the provider is found to be non-compliant the ramifications are significant and can involve; fines, violations, civil charges, payment freezes, disenrollment from federal health care programs and or imprisonment.

2015 fraud and abuse snapshot:

• 2.4 Billion in healthcare fraud and abuse recovered
• 1.9 Billion through civil healthcare fraud cases
• Department of Justice opened 983 criminal health care investigations
• 613 criminal convictions
• Medicare recovered 1.6 Billion through auditing and recovered 2.39 billion in overpayments.

At AccuMed, we want to help you avoid the possibility of the above outcomes. Documentation can play a huge roll in your overall compliance, which is why we help protect our clients by making sure they understand the importance of proper documentation. We’ll keep you up to date on what you need to do. All of our clients are provided with extensive documentation training.

Our training sessions include the following topics:

1. Review the importance of the stakeholders: The Federal Government, The State, Local Medical Control, Hospital, Patient, Agency Administrators, Billing Department and the Medics
2. Medicare Law- Review Medicare Law, Establishing Medical necessity.
3. Very briefly discuss the importance of HIPAA
4. Run Report Documentation – Be Descriptive, provide a complete honest, accurate, objective narrative that paints a picture of the scene and what the Medic did.
5. What is required to paint the picture – discuss documentation suggestions provided by Medicare
6. Review Non-Emergent documentation
7. Interfacility Transports
8. Provide Examples of Incomplete vs. Complete narrative scenarios
9. Review signature rules.

Good documentation is extremely important in our industry, make sure you’re staying informed!