What’s the Deal with Medical Notes?

Incomplete medical notes can have a significant impact on the revenue cycle.

So, what’s the deal with medical notes?Why are they so important, and why are they difficult for providers to complete?

In our last report, we highlighted the significance of eligibility and pre-authorization and provided tips to streamline the process for more efficient revenue collection. This month, we take a step further and delve into the importance of medical notes in the revenue cycle management (RCM) process. 

Medical notes are an essential part of the RCM process, and the information is used to ensure accurate billing and reimbursement for services rendered. The revenue cycle process can be hindered without accurate medical notes, resulting in lost revenue. The cost of poor note-taking can be high, as it can lead to billing errors and increased expenses.

Incomplete notes –> healthcare costs skyrocket

A study published in the Journal of General Internal Medicine found that incomplete medical notes were associated with longer hospital stays and higher healthcare costs. The study analyzed more than 20,000 hospital admissions and found that incomplete notes were associated with a 0.4-day increase in length of stay and an additional $1,386 in hospital costs per patient.

Incomplete notes –> 5-20 percent loss of revenue per provider

A survey conducted by the American Health Information Management Association (AHIMA) found that incomplete or missing documentation can result in a 5-20-percent loss of revenue for healthcare providers. This can be due to a variety of factors, such as denied claims, delayed reimbursement, or lost charges.

Physicians may try to stay proactive in completing notes in a timely manner, but often fall behind with high patient volumes. Common daily patient tracking methods include spreadsheets or notes on pieces of paper. Paper is often set aside and forgotten in a stack of other paper. Excel spreadsheets seem to be the next step up, but is it really a step up?Figures in an Excel spreadsheet are often isolated, and take a much higher degree of technical skill to format into usable data. And with multiple physicians in a practice, often servicing multiple clinic and hospital locations, with new patients coming in daily, detailed notes and physician attestations can fall off the radar quickly. 

When factoring in denials, rejections, and variations in specialties, a rule of thumb for the value of the average claim ranges between $75 to $100 per encounter. So, the losses can add up quickly if notes are not complete, nor attested by the provider.

Incomplete or non-attested notes are becoming much more common

Sometimes, it comes down to a need for oversight. The clinical informatics team auditing a university specialty department found that one of its physicians did not sign more than 3,000 notes. Depending on whether any of those encounters were still submissible at the point of discovery, the potential revenue loss was $300,000. For just one physician. The more physicians to track, the more patient notes at risk of being left behind. It gets complex quickly. With more and more patients coming in daily, detailing notes (which we know is a necessity) becomes a lesser priority.

In a private specialty practice, a provider had not signed 922 notes at one clinical location over a 10-month period. Averaging $100 per encounter, the private practice was at risk of losing $92,200. If that provider’s actions were consistent across their multiple locations, the losses could have bankrupted the practice.

To help organize and flag incomplete encounters, many practices turn toward today’s newer technologies. One such technology, TiaStat’s RCM transparency platform, helps members of the practice capture every eligible encounter by guiding the physician, office staff, coders, and billers through the process, and highlighting missing elements.

Incomplete notes increase the risk of malpractice and put patient care at risk

Notes aren’t just about reimbursement. The impact of poor note-taking can also lead to errors in patient care, such as incorrect medication dosages or missed diagnoses. This can result in additional medical expenses, increased risk of malpractice lawsuits, and patient harm. Consider:

• Incomplete medical notes can result in delays in patient treatment. According to a survey of healthcare providers, 27 percent reported that incomplete or inaccurate documentation had delayed patient care.

• Incomplete medical records are a common factor in medical malpractice lawsuits. According to a survey of malpractice claims, documentation errors were involved in 22 percent of cases.

To reduce the financial, legal, and patient impact of poor note-taking, healthcare organizations should provide regular training for staff on proper documentation techniques, standardize documentation practices, incorporate electronic health records (EHRs), monitor the documentation quality, and incorporate technologies that flag missing or incomplete notes, with some technologies going as far as overseeing the accuracy of coding and billing to mitigate errors.

A study published in the Journal of the American Medical Informatics Association found that incomplete documentation in EHRs was associated with increased malpractice risk. The study analyzed more than 5,000 malpractice claims and found that incomplete documentation was a contributing factor in 7.4 percent of claims.

What’s the difficulty? It takes time

The American Medical Association (AMA) estimates that the average physician spends 13.1 hours per week on paperwork, including documentation and other administrative tasks. This can make it difficult for physicians to find the time to complete medical notes accurately and efficiently.

What is the RCM impact of incomplete medical notes on a practice? 

Incomplete medical notes can have a significant impact on the revenue cycle of a practice, leading to reduced revenue and increased costs. Aside from the examples of the impact of missing medical notes on revenue cycle (shared above), below are statistics of how incomplete medical notes can impact the revenue cycle:

• Billing errors: Incomplete medical notes can lead to billing errors, which can result in denied claims, delayed payments, and lost revenue. According to a survey of healthcare providers, 13 percent reported that incomplete or inaccurate documentation had resulted in denied claims.

• Increased administrative costs: Incomplete medical notes require additional administrative work to review, correct, and resubmit claims. This can result in increased staffing costs and reduced productivity. According to a survey of healthcare providers, 36 percent reported that incomplete or inaccurate documentation had resulted in duplication of efforts.

• Increased audit risk: In the same survey, it was shown that incomplete medical notes increased the risk of audits and investigations by 36 percent, which is costly and time-consuming.

Overall, completing medical notes in a timely and accurate manner is crucial for providing quality patient care, ensuring legal compliance, securing eligible reimbursement in a timely manner, and maintaining efficient workflow in the healthcare system at a time when staff resources are strained.

Today’s technologies have the ability to measure productivity of providers within a practice, track compliance, and assist in recordkeeping. Some technologies help streamline, organize, and highlight missing or incomplete notes.

The return on investment (ROI) on this is immediate, as the technology is able to capture all eligible reimbursements to maximize revenue, and redirect staff resources back to patient care.

Programming note: Listen to Susie Vestevich report this story live today on Talk Ten Tuesdays, 10 Eastern with Chuck Buck and Dr. Erica Remer.