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Medical records, Insurance and Contracts. Chapter 4. Medical Records. There are 5 purposes to medical record: 1) To manage healthcare 2) To track healthcare 3) To track healthcare 4) To meet regulatory requirements 5) To document Healthcare. To Manage Healthcare.
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Medical records, Insurance and Contracts Chapter 4
Medical Records • There are 5 purposes to medical record: 1) To manage healthcare 2) To track healthcare 3) To track healthcare 4) To meet regulatory requirements 5) To document Healthcare
To Manage Healthcare • This is the most obvious reason for keeping medical records. We would not expect a patient to repeat his or her medical history every time they visited the doctor. • Moreover, the medical history of a patient can provide all kinds of important information about a patient in order to better treat him or her in the future.
To Track Healthcare • Why the patient came (symptoms, signs, etc.) • Where the patient received medical care. • What medical care the patient received. • When did the patient receive the medical care. • How the patient responded to the medical care.
To Provide Clinical Data • Some patients may have disease or illnesses that can later serve as data for research and investigations projects. • Some of the data in medical records can also be used to develop statistical information about diseases and illnesses. • This use of medical records is especially important for public health.
To Meet Regulatory Requirements • Medical Health institutions are required by governmental regulatory agencies, regulatory professional agencies, insurance companies, Medicaid and Medicare, to maintain medical records. • Moreover, there are important legal reasons to maintain medical records as well.
To Document Healthcare • Medical Approach: We have already noted many of the medical reasons why marinating medical records are essential for doctors and patients overall well being and health. Healthcare providers should document Why, Where, What, When and How. • Legal Approach: Medical records are legal documents (any work with an author). This means that in any law suit or court proceedings medical records can be subpoenaed and the author (might be you) can be called as a witness.
Subpoena DucesTecum • Attorney’s use Subpoena DucesTecum to obtain medical records because it legally requires doctors and institutions to deliver the medical records to the court. If they refuse the doctor and institution can be fined.
Medical Records and the Law • A central principle of law in treating medical records is that “If it wasn’t written down, it wasn’t done”. • Imagine a case that goes to court. A medical record is subpoenaed to prove malpractice on the part of the physician. The plaintiff argues that certain essential care was not delivered 7 years ago. The doctor and other healthcare workers cannot remember specifically because it was so long ago. However, you remember vividly that the healthcare procedure in question WAS delivered as required. However, the medical records have not documentation that such a procedure was performed. The only evidence you could provide for the court at present moment is the written medical record and a written documentation of the date and time of the procedure and by whom it was administered. Givn the absence of such documentation the court will rule that the procedure was NOT administered.
Medical Record Ownership • The owner of the medical records are the doctors/instuitution tat created them. • The patient is a co-owner of the information in the medical record. • Doctrine of Professional Discretion: A doctor can either edit the information given to patients or refuse to give the information to patients, if the doctor has good justification that such information will be harmful to the patient.
Medical Records • Keeping medical records on file or in storage is crucial for healthcare institutions. • Given that, for many legal issues related to healthcare, there is a Statue of Limitations of 20 years, institutions will keep their medical records for at least this long.
Insurance • Underwriter • Risk of loss • Premium • Deductible • Statistical information: Actuarial Tables
How Insurance Companies Work • Insurance companies are for-profit businesses. • If their actuarial tables do a good job in forecasting the future, then the premiums they collect will be sufficient to pay out any losses. • Insurances companies use the premiums they collect to invest and make money on that money. • There are regulations as to how much money and in what kinds of investments Insurance companies can invest in. • Insurance companies must have a reserve account, to maintain liquid part of their assets portfolio in order to cover healthcare payments of the insured who are ill or sick.
Managed Care • As healthcare costs increased, insurance companies found themselves unable to make as much money as they could make. • In order to have some control over healthcare costs insurance companies became active in what treatments they would and would not pay for.
ICDs and CPTs • International Classification of Disease ICD is the classification of diseases and illnesses that require an overnights stay at a hospital. • Current procedure Terminology (CPT) is a classification for treatment provided by a healthcare professional. • Insurance companies pay a flat fee depending on the ICD or CPT. The difference will either be a loss or a profit for the hospital or doctor.
Upcoding • Upcoding is the fraudulent process of doctors or hospitals providing insurance companies with ICDs or CPTs that pay more than the ones that properly correspond to a patient’s actual disease, illness or treatment undergone.
Malpractice Insurance • Malpractice insurance covers the risk of physician error and as a consequences the risk of being sued. • Employers (hospitals) are responsible for obtaining malpractice insurance for their employees (doctors). • RespondeatSuperior: An employer if responsible for an employees actions. • Therefore, if an employee does something wrong, then the employer can be held responsible. This might sound unfair. • Vicarious liability: This is a legal concept that holds that even though one is not at fault for a given wrong action, the person can be held responsible for damages.
Example • Imagine that a 7-year old child breaks a window. In such a case the parents of the child can be held vicarious liable for the child's actions even though they did nothing wrong.
Contracts • Offer • Acceptance • Consideration • Competence
Contracts • Written • Oral • Statue of Frauds
