Question: Identify three examples of short-term impacts of duplicate medical recordsAddress long-term impacts of duplicate medical records.Describe six key data for patient verification.Summarize a Jo
Seeing double: The financial and patient safety impacts of duplicate medical records Duplicate and overlaid medical records have a ripple effect on the entire revenue cycle—and the entire organization. They’re a source of billing and coding errors, denials, and even serious medical errors that can jeopardize a patient’s health and safety. But at busy hospitals, it’s all too easy for registration staff to make mistakes that lead to duplicate and overlaid records. Although adjustments to staffing and metrics can help ease the pressure on the front end, it can be difficult to get support to make changes that will help reduce errors. The HIM department is often left to clean up duplicate and overlaid records on the back end, draining the depart – ment’s time and resources that are often already spread thin. Untangling records and addressing the associated billing and coding errors can feel like a Sisyphean task. To get ahead of the problem, HIM directors and managers must understand the scope of the problem and how it impacts the entire organi – zation. With a clear understanding and a plan of action, HIM directors and managers can advocate for change and get the buy-in to make the issue of duplicate and overlaid medical records an organizationwide priority. Origin story So just how much of a problem are duplicate and overlaid medical records, and how do they impact HIM? Duplicate and overlaid records carry different risks, and it’s important to distinguish between them when considering the impacts and costs, says Letha Stewart, RHIA, director of customer relations at Plano, Texas–based QuadraMed. A duplicate record means an individual has two medical records with two corresponding medical record numbers and two sets of clinical information. Duplicate records might contain incomplete or outdated information and can affect the quality of care by forcing clinicians to make care decisions without important information such as recent lab results, allergies, and current medications. An overlaid record occurs when one individual’s demographic and possibly clinical information is entered over the information in another person’s medical record. Although overlays are rarer than duplicates, the risks associated with overlaid records are much higher, Stewart says. December 2019 | Volume 34, Issue No. 12 In this Issue HIM BRIEFINGS Writing effective appeal letters Use these tips to craft targeted appeals letters for clinical and technical denials. The career game Explore the full range of options in your HIM career. Sample cancelled account policy Use this sample policy as a template for your organization. P4 Credit: metamorworks. Image Source: www.gettyimages.com P8 P10 2 Overlays and duplicates typically start at the beginning of the patient’s journey: at registration. A combination of inefficient technology and a fast-paced, high-pressure environment sets the stage for errors. The information system and software many organizations use for patient registration have very basic search functionality, Stewart explains. If the registrar misspells a patient’s name—perhaps the patient’s name is Stew – art, but the registrar enters Stuart—the system might not locate the right record. Other common roadblocks to finding the right record are name changes and nicknames. For example, John Smith might have a record under the name Jack Smith. Patients might change their names when they get married or divorced: Linda Smith might become Linda Johnson or Linda Smith-Johnson. And double or hyphenated last names can be especially tricky for limited search functions, Stewart points out. “If registrars don’t do a good job of interviewing patients, things like double or hyphenated last names are a big cause of duplicates,” she says. But interviewing patients isn’t easy, Stewart points out. Busy registration staff might not have time to try multiple variations of a patient’s name if a patient needs to be registered and seen as quickly as possible. Some patients may be unable to give complete, accurate information. In addition, language barriers can further complicate communication. Despite it all, productivity metrics put pressure on registration staff to move patients through at a swift pace. Another common source of duplicate records is trauma patients, Stewart says. It’s not uncommon for a Level I trauma center to have a policy that all patients who are transported by ambulance be registered as a trauma patient before they arrive. These patients might be registered using a naming convention such as Trau – ma 1 rather than their name. This is a useful policy that can allow organizations to better track trauma registries and is necessary for patients who are unconscious or unable to provide information. But organizations need to have a policy that ensures records created for these patients are flagged for follow-up; they also need a process to appropriately link and merge records. Given these considerations, it’s surprising that duplicates and overlays aren’t more common, Stewart says. Generally, most organizations’ duplicate rate is 8%–12%, but it can be as high as 15%–20%. Duplicate records negatively impact not only patient safety but also financial performance, says Rick Greenblatt, vice president of sales and marketing for QuadraMed. According to a 2018 Black Book report , in 2017, 33% of denied claims were due to inaccurate patient identification, costing the average hospital approximately $1.5 million and the U.S. healthcare system more than $6 billion annually. Cleanup Managing duplicate and overlaid records usually falls to the HIM department. That involves creating and reviewing duplicate and overlaid record reports, researching records flagged as potential duplicates and overlays, and merging or separating records. This can be a complicated process with EHRs, which don’t always offer a simple way to merge or separate records, Stewart says. The resources HIM departments can devote to this function varies. Stewart says that she’s seen some organizations dedicate 25% of one full-time employee’s (FTE) workload to managing duplicates and overlays, while other organizations have a team of up to five FTEs handling duplicates on a daily basis. “The larger the organization, the more facilities or locations they have, usually the larger the team and the more formal the structure they’ll have for managing duplicates,” Stewart says. Adding up Duplicate and overlaid records can bloat denials and hold up earned revenue. Incomplete or incorrect information in the record generates coding and billing errors, and demographic information mismatches can put the brakes on earned revenue. An error in patient care can result in a lawsuit that may cost the organiza – tion a significant amount of money plus loss of credibil – ity among consumers. In a 2016 Ponemon Institute survey , 86% of respondents said they witnessed a medical error as a direct result of misidentification. One common example involves surgical procedures, Stewart says. A patient may come to the hospital for presurgical testing and be registered as Elizabeth Smith with medical record number 123. However, when she arrives on the day of the surgery, the registrar can’t find her record and creates a new one under the name Lizzie Smith with medical record number 456. That’s a recipe for an insurance claim denial. HCPro.com | HIM Briefings December 2019 2019 HCPro, a Simplify Compliance brand. 3 “Since those bills aren’t submitted together as the same episode of care for the same surgical procedure, you’re more likely to get a denial for one or both because the presurgical testing is on a different claim than the actual surgery it was being done for,” Stewart says. It’s also common for a claim to be denied if the information on the claim doesn’t match the information that’s on file with the insurer, according to Stewart. There are also likely to be delays in billing if the demographic information is incorrect, she adds. The bill might be sent to the wrong address or have the wrong name on it. Patient safety Duplicate and overlaid medical records pose a serious risk to patient safety. In an article in the September 2018 issue of the Journal of AHIMA, Shannon Harris, MBA, RHIA, and Shannon H. Houser, PhD, MPH, RHIA, FAHIMA, discussed how duplicate and overlaid records can lead physicians and other clinical staff down the wrong path. “For example, a physician may locate two records for a patient and select only one of the records as a reference for how he/she would administer treatment for the patient,” Harris and Houser wrote. “This physician could then prescribe a medication for the patient that produces an adverse reaction, causing the patient to be referred for emergency treatment.” It’s a problem that is at best frustrating for physicians and patients, Greenblatt says. At worst, it can endanger patients and increase medical malpractice risk. Wasteful spending With clinical information split between multiple records, physicians may order tests that have already been performed or explore diagnoses that were defini – tively ruled out. In an era of heightened healthcare spending and utilization scrutiny, that’s bad news. “We’re moving into an era of value-based care where reimbursement is based on quality and outcomes,” Greenblatt says. “Duplicate records definitely have an impact, and it’s an underlying issue that hospitals aren’t fully aware of until they look underneath the covers.” Most organizations know their days in accounts receivable or which surgeons incur the highest costs for total hip replacement, but fewer have a handle on their duplicate record rate, according to Greenblatt. How – ever, getting a definitive answer can be difficult because it often relies on reports from the same EHR system that, due to search limitations, can be a source of duplicate records. Because most hospital registration systems use very basic search algorithms, they tend to create a high rate of duplicate records, which means the duplicate record reports they generate are going to be inaccurate, Greenblatt points out. Building solutions Unfortunately, there’s no easy fix for duplicate and overlaid records. Although HIM is responsible for managing them on the back end, moving the needle requires addressing the root of the problem on the front end, Greenblatt advises. Registration staff should be properly trained, and organizations should consider adjusting productivity metrics and adding technology solutions, Stewart says. Registration staff should know how to spot red flags that will alert them to the possibility of creating an overlaid record. If they find themselves actually chang – ing a patient’s date of birth or Social Security number, they should stop and consider what they’re doing, Stewart recommends. It’s not uncommon for some demographic information such as addresses or names to change, but an individual’s date of birth won’t change. Although it’s possible that the information in the record is in fact erroneous, registration staff should first dig deeper with the patient to determine if they have the right record. To combat duplicates, registration staff should be trained to properly interview patients, Stewart says. Registrars should ask patients if they have ever been a patient at the facility and if they’ve ever used a different name. If a patient says they have been treated at the facility before but the first search doesn’t turn up any matches, the registrar should dig a bit deeper. “One of the biggest factors is they have a limited amount of time to do it in. The actual identification part is a very small part of what a registrar has to do. So if a registrar is expected to spend three minutes with the patient, finding the correct patient and making sure that you have correct information is maybe 30 seconds of that,” Stewart says. Organizations should set realistic standards and expectations for how long registration takes and con – HCPro.com HIM Briefings | December 2019 2019 HCPro, a Simplify Compliance brand. . 4 sider that not every registration is the same. It may take longer to interview a patient if there is a language barrier, for example. “Registrars definitely feel that they’re in a time crunch, and anything the facility can do to give them adequate time to locate the correct patient is going to help them in the long run,” Stewart says. “It takes maybe one extra minute on the front end to register the patient correctly, thereby preventing a duplicate or an overlay. On the back end, it takes anywhere from 30 minutes to a couple of hours to correct a duplicate, and it can take upwards of 20 hours to correct an overlay.” In addition, a duplicate or overlaid record can quickly become a systemwide problem, she says. Most hospitals interface with systems used by radiology, labs, and other downstream systems and ancillary depart – ments. If there’s a duplicate in the primary EHR, the error may make its way to those other systems. Duplicate and overlaid records are a costly and complicated problem and can be a huge drain on HIM’s resources. HIM directors and managers looking to get relief should work with registration and patient access directors to put together a case for a comprehensive front-end solution. Dig into the data to find a reliable duplicate rate and use that to determine how to allocate HIM’s resources. Cleaning up duplicate and overlaid records will help your organization operate more efficiently and keep patients safer. Writing effective appeal letters by Lynette Kramer, MA , RHIA There’s an art to writing effective appeal letters. A good appeal letter increases your odds of overturning a denial and being paid appropriately for services pro – vided at your organization. But when it’s time to craft that letter, it’s easy to get stuck. What information should be included? How should the letter be struc – tured? What do you need to provide to properly sup – port your statements? General tips Start with the basics of writing. First, map out a logical outline or structure. This will guide your writing and will help ensure that you include all the relevant information—and only the relevant information. Then draft and review the letter to make sure that it’s clear, concise, and logical. Use the correct terminology, but avoid using unnecessarily complex language that may obscure your point and confuse the reader. If your letter includes a long list, consider making it a bulleted list so the reader can easily grasp the information. Finally, ensure that the letter engages the reader by telling a story supported by facts. Each appeal letter should contain certain critical components. Provide basic information to identify the case, such as the patient’s name, account number, and the dates of service. Restate the reason for denial; this is critical to crafting a successful response. Outline a clear statement of disagreement that lays out why you think the denial was made in error or why an exception should be made. If you’re arguing that the denial was made in error, include supporting evidence proving the error, such as an eligibility response screenshot or quoted contract language. Conversely, an exception to the denial can be made by providing excerpts of the medical record or by including clinical evidence sup – porting your appeal strategy. Always provide contact information, including both an email and phone number, so the payer’s reviewer can get in touch with the appropriate individual at your facility. Clinical appeals Clinical appeals are always challenging. Let’s take a closer look at how to win an inpatient medical necessity denial. The first steps are to provide a brief overview of the reason for the denial and outline the organization’s approach for determining level of care. Common clinical criteria include InterQual and Milliman. The following checklist can be used to evaluate your appeal letter response. Your letter should include: • The date of service and the pertinent details about care prior to this date of service. – Tip: If applicable, describe the failure of out – patient care that necessitated an inpatient level of care. • Emergency department treatment, when appropriate. – Tip: If applicable, include symptoms that re – mained after treatment and what treatment was intended for the admission. 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