Provider Record Audits/Clinical Documentation Reviews

Clinical documentation is imperative in today’s health care environment for a variety of reasons with maximizing reimbursement, effectively decreasing risk and streamlining operations to name a few. In addition to these, however, the most important factor of all is providing quality patient care. Healthcare organizations, third party payers as well as individual practitioners realize the importance of proper compliance and documentation.

Our company has audited thousands of provider records in hundreds of clinics across the country. Most traditional audits are focused simply on billing procedures, proper coding and reimbursement tactics. While billing properly is of utmost importance, we also work closely with health care organizations, third party carriers and governmental agencies to identify specific clinical deficiencies to help mitigate liability, ensure proper payment is issued and detect potential fraud when applicable. With the rising risk of litigation and health care fraud, malpractice carriers, third party payers, legal representatives, governing agencies and providers alike are all concerned with potential fraud, litigation and proper reimbursements.

Practicing the acceptable standard of care can help decrease the chances of exposure on several levels. Licensed doctors will benefit by being able to correct any deficiencies discovered hopefully avoid disciplinary action by their state licensing board or governing agencies and help identify contraindications/high risk patients prior to delivering care. Additionally, companies will hopefully rest easier knowing that records are being monitoring for proper clinical compliance and billing practices thus mitigating financial/legal risk, increasing profitability and enhancing patient care.

The provider record audits help ensure that the following necessary components are included in the treatment record:
  • Identification of the patient's name, address, date of birth, sex, and parent/legal guardian noted, when applicable
  • Proper Diagnosis
  • Completed history including applicable components of "OPQRST"
  • Adequate examination findings
  • Completed vitals
  • P.A.R.T. components properly documented when applicable
  • Proper treatment protocol
  • Treatment plan
  • Visit fee amount
  • Follow up recommendations
  • Name of the doctor providing service

Operational Systems Analysis

Every successful organization needs effective operating procedures to function at its highest level yet it is often the most overlooked. Based on our experiences of overseeing, owning and consulting with some of the largest chiropractic providers in the country, we have identified the key and most productive procedures to operate a successful clinic. The purpose of an operational systems analysis is to evaluate your present operations and make recommendations of how to communicate those procedures in the most efficient fashion.

Our Standard Operating Procedures (SOP’s) and Protocols have been designed to support serving the greatest number of new patients, converting them to long-term recipients of care. In doing so, the desire is to provide a great consumer experience at the clinic level each and every time. The ultimate goal is to develop and foster lifelong Doctor/Patient relationships built on trust, learning and compassion.

These measurable standards are intended to guide the delivery of a consistently superior level of patient care each time regardless of the size of the clinic or company for daily use. They define what the consumer should experience and what we must do to deliver consistent, high-quality service and care for every patient, every visit. Operating procedures are the daily and ongoing processes and activities that are performed to ensure that proper standards are delivered throughout each day in the highest quality. Tools, or the physical devices that are needed to complete the procedures, are also identified along with Job aids to perfect the quality of the task performed.
Properly written and communicated SOP’s are imperative to increasing your bottom line and streamlining operations.

Additional consulting services offered include:
  • Effective Growth and Expansion Strategies
  • Risk Assessment/Management
  • Wellness Programs
  • Office Policies
  • Improved Doctor/Employee Relations and Production
For more information concerning our healthcare consulting services, please CONTACT US.