Compliant Records Retention

The U.S. Department of Health and Human Services Office of Inspector General’s (OIG’s) model compliance plan recommends that physician practices designate procedures for records’ retention, to include documents relating to patient care and the practice’s business activities. Practice standards should address the creation, distribution, retention, and destruction of documents. If your practice decides to implement a records system, you should also consider privacy concerns and Federal or State regulatory requirements.
The OIG specifically suggest the following record retention guidelines:
• You may specify the length of time that a practice’s records are to be retained in the physician practice’s standards and procedures. Consult Federal and State statutes for necessary minimums, if applicable. For instance, HIPAA retention period is six years from creation date, or from the date when the record was last in effect. You may keep records indefinitely in risky situations (including where there is an undesirable outcome), when a patient threatens or files a lawsuit, etc.
• If medical records are in possession of the practice, you must secure them against loss, destruction, unauthorized access, unauthorized reproduction, corruption, or damage.
• Standards and procedures may stipulate the disposition of medical records if the practice is sold or closed.
The OIG recommends, but does not require, that you retain documentation to record compliance activities. The benefit of doing so is that you can show diligence in avoiding and investigating compliance lapses. The primary compliance documents that a practice should retain are those that relate to educational activities, internal investigations, and internal audit results.
For example, the practice or medical organization will need a written directive regarding maintenance and retention of training and education records. Records of each individual’s attendance at all training and education seminars should be documented and retained in his or her HR file. During an annual review of employee records, the practice or medical organization will need to audit these training records to ensure that the training requirements have been met.
While conducting your compliance activities, as well as your daily operations, you should document all efforts to comply with applicable Federal health care program requirements. For example, if your practice requests advice from a Government agency (including a Medicare carrier) charged with administering a Federal health care program, it is to your benefit to document and retain a record of the request, as well as any written or oral response (or non-response). This is important if the practice intends to rely on that response to guide it in future decisions, actions, or claim reimbursement requests or appeals.

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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