The Compliance Guy

Episode 370 - #TerryTuesday - Documentation is Key Regardless of Who's Paying


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Summary

In this episode, Sean and Terry discuss the critical importance of proper documentation in healthcare, particularly focusing on the discrepancies that arise when dealing with cash patients versus insured patients. They emphasize that documentation should be consistent and thorough, regardless of the patient's financial status, to mitigate compliance risks and protect both providers and patients. The conversation also touches on the broader implications of healthcare practices, including the influence of insurance companies and pharmaceutical companies on treatment options.

Takeaways

  • Documentation should be universal across all patient types.
  • Cash patients often receive inadequate documentation.
  • Proper documentation protects against medical liability risks.
  • Providers must document services regardless of insurance coverage.
  • Documentation is essential for continuity of care.
  • Inadequate records can harm patient care and outcomes.
  • Compliance risks increase with poor documentation practices.
  • Providers are responsible for documentation even after retirement.
  • Audits can go back six years, regardless of provider status.
  • Be proactive in documentation to prepare for audits.


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The Compliance GuyBy Sean M. Weiss

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