Legal and Ethical Issues Legal and Ethical Issues

Carolyn Heyman-LayneCarolyn Heyman-LayneDorsey & Whitney LLPDorsey & Whitney LLP

September 2008September 2008

Legal and Ethical Issues in Legal and Ethical Issues in DocumentationDocumentation LegalLegal

State LawState Law Federal LawFederal Law General LiabilityGeneral Liability ContractsContracts AuditsAudits

EthicalEthical Conflicts of InterestConflicts of Interest Revision of RecordsRevision of Records Disposal of RecordsDisposal of Records

State & Federal LawState & Federal Law

AlaskaAlaska Document Document

RetentionRetention Medicaid Medicaid Reporting Reporting

RequirementsRequirements Specialized Specialized

RecordsRecords

FederalFederal HIPAAHIPAA MedicareMedicare MedicaidMedicaid JCAHOJCAHO

Alaska MedicaidAlaska Medicaid Documentation is key to Documentation is key to

successful auditssuccessful audits Public Guidance:Public Guidance:

StatutesStatutes RegulationsRegulations Provider ManualsProvider Manuals Department GuidanceDepartment Guidance WebsiteWebsite

Check and double-checkCheck and double-check Always record your source!!!!Always record your source!!!!

Federal LawFederal Law HIPAAHIPAA

Documentation of HIPAA Documentation of HIPAA compliance should be in the compliance should be in the recordrecord Notice of Privacy PracticesNotice of Privacy Practices Record of DisclosuresRecord of Disclosures Amendments to RecordsAmendments to Records Patient RequestsPatient Requests

Always remember that HIPAA Always remember that HIPAA gives patients access to the gives patients access to the recordrecord

Federal LawFederal Law

Medicare/MedicaidMedicare/Medicaid Medicare and Medicaid do not Medicare and Medicaid do not

always have the same always have the same documentation requirements – be documentation requirements – be sure to checksure to check

Double-check all documentation:Double-check all documentation: Patient eligibilityPatient eligibility Billing statusBilling status Contracts with patientContracts with patient Contracts with governmentContracts with government

General LiabilityGeneral Liability

LawsuitsLawsuits PatientsPatients ProvidersProviders InsurersInsurers

Failure to have compliance Failure to have compliance policies and procedurespolicies and procedures

Failure to obtain proper consentFailure to obtain proper consent

ContractsContracts

Hidden documentation Hidden documentation requirementsrequirements Insurance companiesInsurance companies Government Government

Medicare/Medicaid ContractsMedicare/Medicaid Contracts Certificate of NeedCertificate of Need Settlement AgreementsSettlement Agreements

TribalTribal Funding AgreementFunding Agreement CompactCompact

AuditsAudits

Sufficient documentation is the Sufficient documentation is the key to a successful auditkey to a successful audit What you think is sufficient may What you think is sufficient may

not be enoughnot be enough Guidance from national practice Guidance from national practice

organization may not be enoughorganization may not be enough Over-the-phone guidance may not Over-the-phone guidance may not

be enoughbe enough Information from public meetings Information from public meetings

may not be enoughmay not be enough

Audits: When it happensAudits: When it happens Address the auditor requestAddress the auditor request Number the documents Number the documents

providedprovided Keep a copy of all documents Keep a copy of all documents

providedprovided Request clarification, if Request clarification, if

necessarynecessary Do a self-audit before sending Do a self-audit before sending

records outrecords out Resolve issues, if possible and Resolve issues, if possible and

ethical…ethical…

Documentation: Ethical IssuesDocumentation: Ethical Issues

Conflicts of InterestConflicts of Interest Revision of RecordsRevision of Records Disposal of RecordsDisposal of Records

Conflicts of InterestConflicts of Interest

Conflicts can affect Conflicts can affect documentation through:documentation through: Patient relationshipsPatient relationships Small communitiesSmall communities Personal liabilityPersonal liability Professional liabilityProfessional liability Job implicationsJob implications

UH-OHUH-OH

Conflicts of InterestConflicts of Interest

How do you address a potential How do you address a potential conflict?conflict? DiscloseDisclose Be objectiveBe objective Find a replacementFind a replacement Work with a partnerWork with a partner Be sure documentation reflects all Be sure documentation reflects all

actions taken to address the actions taken to address the conflict, but not necessarily in the conflict, but not necessarily in the medical recordmedical record

Revision of RecordsRevision of Records

What do you do if a record is What do you do if a record is incomplete?incomplete? Add reliable info and substantiateAdd reliable info and substantiate

What do you do if a record is What do you do if a record is incorrect?incorrect? Amend and documentAmend and document Substantiate amendmentSubstantiate amendment

What do you do if a record is What do you do if a record is missing?missing? Document efforts to locateDocument efforts to locate Recreate what can be substantiatedRecreate what can be substantiated

Disposal of RecordsDisposal of Records

Make sure document retention Make sure document retention period has passedperiod has passed

Make sure no litigation hold is in Make sure no litigation hold is in placeplace

Double-check statute of Double-check statute of limitations for potential limitations for potential controversiescontroversies

Shred or otherwise destroyShred or otherwise destroy Be careful with electronic Be careful with electronic

recordsrecords

Electronic Medical RecordsElectronic Medical Records

Documentation should not be Documentation should not be less than paper recordsless than paper records

Documentation should be Documentation should be unique to patient and treatment unique to patient and treatment – no “cut and paste”– no “cut and paste”

Always store backupsAlways store backups Have emergency procedures in Have emergency procedures in

placeplace Confirm acceptance with payerConfirm acceptance with payer

Questions?Questions?

Carolyn Heyman-LayneCarolyn Heyman-Layne

Dorsey & Whitney LLPDorsey & Whitney LLP

1031 W. 41031 W. 4thth Avenue, Suite 600 Avenue, Suite 600

Anchorage, AK 99501Anchorage, AK 99501

(907) 257-7870(907) 257-7870

Heyman.carolyn@dorsey.comHeyman.carolyn@dorsey.com