Towards Minimizing Legal Errors In Handling Medical Records

Despite such indicators from time to time, the incidence of legal errors has only been destined skywards. Physicians, whose core-concern being medical efficiency through best medical practices, can not be expected of too much in this regard. Yet, because of it being integral to their practices’ sustenance and growth, its significance cannot be underestimated.

Notwithstanding physicians’ integrity in safeguarding medical information revealed by patients or discovered during the course of treatment, there have been instances of physicians running into legal issues on account of erroneous (though unintentionally) management of patient medical records. Irrespective of the intention, in view of adverse repercussions – severity of punishment ranging from civil charges (fines and suspension of practice) to criminal proceedings, including cancellation of practice license, and imprisonment – emanating from such erroneous management of patients’ medical information, it is advisable that physicians’ adhere to American Medical Association’s (AMA) ethical guidelines that govern the code of conduct on management of patient’s medical information; HIPAA guidelines are specifically formed and amended from time to time in this regard – the latest being the HIPAA 5010 scheduled to come into effect from October, 2013. Although AMA’s guidelines are not as legally binding as Federal or State-specific laws, yet – given the ethical nature of medical practice – judiciary has tended to being more approving of AMA’s guidelines. Therefore, physicians can deem AMA’s guidelines as the yardstick to measure their conduct of patients’ medical information.

Though, the proverb, ‘experience is the mother of wisdom’, holds well universally, yet, physicians cannot leave their practices for a chance at as dangerous a thing as legal error in handling medical records. Alternatively, they can avoid committing the usual errors that have been identified over the years. Here are some of the frequent errors that physicians have tended commit while handling patients’ medical information:

• Denying patients complete access to their medical records:
  Physicians have been reported to have presumed that their patients can be satisfied with partial access to their medical information. Though physicians have every right to withhold any information that may be damaging to a patients’ confidence or well-being, yet, in general cases, they should provide complete information as sought by their patients.
• Refusing to share a copy of the report with the patient:
  There have instances wherein Physicians have been summoned up by the law for refusing to share copies of medical reports with their respective patients. Therefore, it is a bounden duty of physicians to honor requests for copies of medical reports by their patients.
• Presuming that a non-custodial does not have a right to ask for a minor’s medical record: Proven wrong by the law (both Federal as well as State-specific), doctors should get rid of any such inhibitions as they might invite legal battles.
• Presuming HIPAA as the ultimate controller of patient information disclosure:
  Although HIPAA rules the roost in majority of cases, yet, there are areas where Federal and State-specific laws supersede HIPAA. Therefore, Physicians need to be mindful of parallel laws that work in tandem with HIPAA’s ethical guidelines for handling medical records.
• Honoring requests without being duly signed by the patients:
  Honoring requests of Data (PHI) sharing without being duly signed by patients can invite trouble if such requests happen to be unscrupulous. Therefore, physicians or their staff needs to verify every request for patient signature, which is deemed authentic by Federal as well state-specific laws.
• Denying requests for records on account of unrealized fees from patients:
  While physicians have every right to realize their fees from patients, they cannot cite it as the reason for refusing request for records. Alternatively, they can only recover copying charges for such medical reports.
• Deeming it a right to charge patients for medical records:
  Although physicians have right to recover nominal fees for sharing copies of their patients medical records, they are not authorized to impose discretionary charges. At the most, they can include incidental charges such as postage and handling. The Federal as well as state-specific laws are very stringent on this. Therefore, physicians should avoid running into embarrassment for being unduly expensive.

Despite such indicators from time to time, the incidence of legal errors has only been destined skywards. Physicians, whose core-concern being medical efficiency through best medical practices, cannot be expected of too much in this regard. Yet, because of it being integral to their practices’ sustenance and growth, its significance cannot be underestimated. Therefore, they need to source some kind of medico-legal advisory to mitigate the probability of committing errors in dealing with patient medical information.

With internal advisory proving either costly or ineffective, outsourcing seems to be the better option. Medicalbillersandcoders.com (www.medicalbillersandcoders.com), whose comprehensive medical billing management comes with a special feature dedicated to solve issues related to diverse situations in patient medical information handling, should offer physicians the much awaited respite from getting into legal tangle. The additional training to physician administrative staff and updates on billing and legal issues makes Medicalbillersandcoders.com the ideal platform for all physicians.

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Published By - Medical Billers and Coders
Published Date - Oct-07-2011 Back