Wiki Lost records - can we bill the insurance?

[LINDA]

We are a hospital based practice and the hospital where we practice had a major system issue where the EHR was down for several weeks. Our physicians documented using paper notes and those notes were supposed to be scanned into the hospital chart after the system came back up. It has now been about 2 months and many of our physician's notes now appear to have been lost. Two questions - can we/ should we recreate those notes as "late entry" notes and can we bill for those services? We do not see any Medicare patients but we do see Medicaid if that makes any difference. Any advice?

 

[amyjph]

This question needs to go to your compliance department and attorney.

 

[LINDA]

We are a very small practice and we don't have an official compliance department. We have several certified coders and we try to keep up on all compliance issues but this is over my experience level. I'm not even sure we have a practice attorney.

 

[csperoni]

I would imagine if your practice is hospital based, that there are some type of resources available to assist you. Maybe you belong to an IPA that could assist. This is such a concern to me that even if you don't have a standard practice attorney, I would hire one to review this issue. To me, the billing issue is actually the lesser issue here.
This is in NO WAY official advice, but if I was the person making this decision:
1) I would first make a thorough search for the records that were completed on paper. Perhaps they were all scanned into a particular file and not uploaded to the individual charts. Who took those papers from you and where did they go from there?
2) If the paper records are all indeed lost, from a patient care perspective only, I would make some attempt to document what you could. Something like a standard sentence in the beginning of each document with something like:
This note is being re-created on a later date due to a computer systems error resulting in documentation unable to be located. The documentation below reflects the services that took place to the best of my recall.
Followed by whatever the clinician can remember about the patient/encounter. For your ongoing patients, this will be better than nothing.
3) I would not bill those services to insurance unless advised by compliance, an attorney, or the insurance company, IN WRITING.
Good luck!

 

[LINDA]

I would imagine if your practice is hospital based, that there are some type of resources available to assist you. Maybe you belong to an IPA that could assist. This is such a concern to me that even if you don't have a standard practice attorney, I would hire one to review this issue. To me, the billing issue is actually the lesser issue here.
This is in NO WAY official advice, but if I was the person making this decision:
1) I would first make a thorough search for the records that were completed on paper. Perhaps they were all scanned into a particular file and not uploaded to the individual charts. Who took those papers from you and where did they go from there?
2) If the paper records are all indeed lost, from a patient care perspective only, I would make some attempt to document what you could. Something like a standard sentence in the beginning of each document with something like:
This note is being re-created on a later date due to a computer systems error resulting in documentation unable to be located. The documentation below reflects the services that took place to the best of my recall.
Followed by whatever the clinician can remember about the patient/encounter. For your ongoing patients, this will be better than nothing.
3) I would not bill those services to insurance unless advised by compliance, an attorney, or the insurance company, IN WRITING.
Good luck!

This is what I was thinking but since this is outside my experience level, I wanted other thoughts as well. Our physician's records were left in the hospital unit to be scanned with the rest of the hospital charting. The hospital is the one who is in charge since it was their EMR that went down and we are working with them to locate our original physician notes. Luckily we've narrowed down to only a few missing physician notes, but the rest of the hospital chart is there so hopefully our providers can re-create their note from other information in the record. Thank you so much for the suggestions!