Documentation in Clinical Records

Having some knowledge of the importance of the clinical record and how that record can protect and defend the doctor and the practice, I’m asked to conduct independent audits of those clinical records from time to time.

Often a dentist will need a second opinion subsequent to an insurance company audit, a regulatory board investigation or when there is some type of action against the doctor pending. In fact, I just finished another audit and the issues remain the same. “The documentation does not support the treatment provided.” This doctor faces significant financial loss. The entity is asking for repayment for the “unjustified” services and the demand is substantial. OUCH!

When these audits are conducted, they typically are not done for all the patients covered by the plan. The administrator of the plan conducts a “random” audit of, say, 20 patient charts that have been covered by the plan. If that audit suggests that 10% of that amount paid to the doctor was paid in error, the plan will use an extrapolation formula. The administrator will tabulate the entire amount paid to the doctor over a period of time by the plan, multiply that entire amount by the 10% established in the audit and ask for (demand) 10% back based on the entire amount paid to the doctor over a specified period of time. Does that get anybody’s attention? It should!

Legally, if it’s not in your dental record, you didn’t see it, you didn’t say it, you didn’t do it, it didn’t need to be done and it doesn’t exist from a legal perspective. Be careful to document in such a way that there’s no question left unanswered, no service provided left to the imagination. The dental record should read like a story that has a beginning, middle and end where everything is recorded. I know, I know, there are only so many hours in a day, but ask this doctor who will most probably write a six-figure check what he thinks today. The time taken to document completely would have been very well spent and could very well have prevented this action.

When you are tempted to cut corners in your recordkeeping, billing, and coding systems, weigh the consequences and choose wisely. Defending yourself and your practice … priceless.

About the author: Dr Roy Shelburne is a graduate of Virginia Commonwealth University’s School of Dentistry and practiced in Pennington Gap, VA for 27 years.  He worked with Baptist Medical Dental Mission International from 1997 to 2006 and served as president of the Southwest Virginia Dental Association and preceptor for the Virginia Commonwealth University School of Dentistry.  In 2008, Dr Shelburne began serving a 19-month prison sentence for health care fraud, racketeering and structuring.  He learned the hard way that ignorance is no excuse in the eyes of the law.  Today, Dr Shelburne is free, has gone through the detailed process of getting his license reinstated, and is practicing dentistry again in Virginia.  He is a speaker, writer and consultant specializing in record keeping, billing/coding and office efficiency.

This blog is intended for general information purposes only. The information presented does not constitute legal advice and should not be relied upon as such. Always consult an attorney regarding legal issues and implications.