Address Security, Policies, Contracts when Reviewing Your Medical Practice

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This article is Part 2 in a two-part series that discusses several important areas to address when conducting a “check-up” of your practice. Part 1 was published in the July issue of ENTtoday.

The only way to be confident that your practice is performing well is to conduct periodic internal reviews of your practice operations. This allows you to familiarize yourself with the intimate details of your practice operations and identify what you are doing well and what needs improvement. Doing so will not only help your practice to become more compliant, but will also make it more valuable to potential purchasers. Don’t wait until it’s too late. Avoiding unfavorable issues that could have been resolved through regular internal reviews can result in government findings or may force a potential buyer to walk away.

Medical Records Review and Security

Ensure that your medical records clearly and accurately document each patient’s health status, medications prescribed, and history of treatment provided, including referrals to other providers, to improve quality and continuity of patient care. Also, be sure your medical records document the medical necessity of the service provided in order to maximize reimbursement by preventing claims from being rejected or down-coded by payers. Regular training should be conducted to ensure routine performance of these steps.

Are your medical records stored in a secured, central location, accessible only to authorized personnel at your office? Although it is important that medical records be easily retrievable, they must be stored in a locked cabinet or room when not in use. Electronic medical records should be securely maintained in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the HIPAA Security Rule.

Fixed Assets and Supplies Inventory

Regularly review the equipment owned or leased by your practice to ensure it is functioning as intended. If necessary, have your equipment serviced to improve performance. If you lease any equipment, review the lease agreement to determine maintenance requirements; this agreement may require improvements to be completed by a third party. If necessary, upgrade outdated or poorly functioning equipment. Also, review your supply inventory monthly to determine how supplies are being used and whether adjustments can be made to save costs.

Policy and Procedure Review

Due to the evolving nature of the laws and regulations impacting the practice of medicine, it is critical that you annually—or more regularly if necessary—review your practice’s written policies and procedures to confirm that they accurately describe how your practice operates. If you do not have a written policy and procedure manual, make it a priority to implement one that includes the following: