Etiquette For Your Medical Practice

Giving Medical Advice

Current patients and even new patients to the office often call the office for medical advice over the phone.  The receptionist does not have the medical authority to answer these types of questions.  The receptionist should never give suggestions or advice for medical care to a patient.  The best way to handle this situation is to let the caller know that you are not qualified to give out medical advice.  They can then ask the patient to make an appointment so that the physician can recommend treatment.  Or the patient can be transferred to the nurse, nurse practitioner or physician who can give them further medical advice. When given to the proper person who can give medical advice, this should always be out of earshot of other patients so as to keep that patient’s confidentiality private.  Usually a medical practice has a private office that an appropriate staff member can give results to patients without the possibility of other people hearing them.

Patient Confidentiality

Making sure patient confidentiality is enforced is the one of the most important things when communicating with them.  This falls under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  This law forbids medical staff from releasing any information about their patient unless specified by the patient themselves.  If a family member of a patient calls the medical office for any type of medical history or want results of tests that have been performed on the patient, this is not allowable under the HIPAA regulations.  The staff member should inform them that they are not allowed by law to give out medical or personal information from the patient’s chart.  When requesting records whether it be another medical office, law office or even the patient themselves, a signed medical records release form should be signed and dated by the patient giving the appropriate person the right to view their records.

Switchboard Operation

Some medical offices operate a switchboard in their offices.  When doing this there are a few things to keep in mind.  Keeping track of what patients are on hold will keep the lines of communication open.  Most medical practices have multiple lines that can accommodate several lines at one time.  Make sure that the receptionist asks the caller for their name and phone number, then place them on hold and refer the line to the appropriate person.  The tone of voice of the staff member should always be polite and professional. If the person is not available then they should take a message along with the patients name, phone number, alternate phone number, reason for calling, date and time that the call was received and then give the message right away to the appropriate person.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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Keys To Keeping Good Medical Records

Medical records are an important part of any medical practice.  Keeping good records is essential in avoiding an audit or possibly not getting payment from an insurance company.  Several auditing groups include, licensing boards, payers, litigants, accreditation organizations, each one is looking for specific things in the documentation.  Licensing boards want to find out if the doctor acted within his or her scope of practice or if they were grossly negligent.  Payers want to determine if a claim is justified for reimbursement.  Litigants want to know whether a breach happened during care.  Accreditation organizations want to determine if their standards and elements of performance have been met by the doctor.

These are some general requirements for documentation.

  1. Medical Records should be complete and are legible.
  2. Documentation of each patient that is being seen should include a reason for the visit and a history that is relevant to the complaint, physical examination findings and any prior diagnostic test results, a full assessment and clinical impression and diagnosis, a plan for care and date the record along with signature of attending physician, nurse etc.
  3. Reason for ordering tests.  If this is not recorded, it can be easily proved that it was not necessary.
  4. Past and present diagnoses whether it be from the patient or other past office visits from other physicians.
  5. Appropriate health risk factors should be identified and noted.
  6. Patient’s progress, response to changes in treatment, and a change of diagnosis should be clearly documented.
  7. The CPT and ICD-9 codes reported on the insurance claim form should always be supported by the documentation in the medical record.

Meeting the standard of care medical records must:

  1. Document any details regarding a patient’s history during the exam
  2. Document referrals
  3. Document refusals of treatment and the reason the patient has refused treatment
  4. Document that the physician has clearly reviewed the possible consequences of refusing a specified treatment to the patient
  5. Document encouragement of the physician of healthcare maintenance and risk reduction (example: weight loss or smoking)
  6. Document advice that has been given to the patient (example: pink eye can spread to others in the family)
  7. Document patient noncompliance with treatment regimen or referral, including the patient’s reason for not complying and advice to the patient about the risk of failing to take the advice given.

Good medical record keeping is an important part of good business.  The consequences of errors can result in a denial of payment, audit, loss of contracts, accreditation or possible lawsuit brought on by a patient.  It may take longer to do but in the end it benefits you, your practice and most important of all your patients.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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Commonly Asked Medicare Q & A

As an outsourced medical billing company I get many questions regarding Medicare.  I will keep track of these questions and publish some of them periodically on my blog.  Below are answers to three commonly asked questions.

Do Medicare rules apply to patients who don’t have Medicare?

Medicare has rules called “conditions of participation” regarding facilities and home care agencies and these rules apply whether or not the patient has Medicare.  In order for the facility to maintain its Medicare provider status, it must meet the conditions of participation.  On the other hand, Medicare only stipulates that these rules only apply to Medicare patients and do not have any connection with other payers.  So if there is a patient that comes in for an office visit and they do not have Medicare or any other type of insurance and will be paying for the visit themselves, the provider does not have to accept Medicare’s rates and does not have to meet Medicare’s required documentation or disclosure requirements or Medicare’s performance measures.

What constitutes an “Initial Visit” for Medicare billing?

For example, if a patient comes into the office to receive results of a sleep study can this be billed as an initial visit?  An initial visit or a “new patient” visit is a face-to-face visit.  If you are going over and giving the results of the sleep study with the patient present and have given further instruction and have a treatment plan, this is an initial visit.  If the patient is not present when giving the results, then this is not a visit.  According to Medicare, a patient qualifies as a new patient when they have not been seen in over 3 years.  If the patient has not been seen for over 3 years, an initial visit can be billed.  If a patient visits the hospital, then one initial visit per patient per hospitalization is allowed.  All other visits while the patient is hospitalized are to be billed as subsequent visits.

Can more than one Nurse Practitioner bill a Medicare patient on the same day?

In some cases this is allowed.  For example, if there are two Nurse Practioners one being the primary care nurse that bills Medicare one diagnosis and the other Nurse Practioner being in a specialty practice bills for a different diagnoses on the same day.  Will the bills for these visits through two separate practices and two separate provider numbers be paid by Medicare?  Yes. According to Medicare rules, both claims would be paid.  The reason they will be both paid is due to their being two different diagnoses on each claim and the bills are being generated by two separate providers.  However, when there are cases of two Nurse Practitioners who have billed for the same day with the same diagnosis, it is likely that one of these claims will be rejected by Medicare.  In this case, it is extremely important that the Nurse Practitioner has justification through their progress notes to back up their claim.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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Billing Practices That Can Be Costly – Part I

Obviously, to receive proper reimbursement it is very important to have accurate coding practices for all health care practitioners however; here are several reasons.  A group that is often involved in the billing process is nurse practitioners. Generally they are billing for their own services or they may be using a billing form (superbill) provided by their employer by marking procedural codes and diagnostic codes in order to bill for their services.  The responsibility for the accuracy of the coding and billing, as well as for maintaining medical records that support the diagnosis code and procedural code that is being used to bill for specific services, is the professional provider or the nurse practitioner. 

Keeping up to date with accurate coding procedures is very important when billing to receive maximum reimbursement.  However, due to new codes being added, modified or deleted, this may cause an impact on reimbursement.  Sometimes the definition of a code may not be so clear.  That’s why it is vital to utilize sources that are available to the medical community.  Such as workshops, online information and online telephone consultation services for health care providers to get better clarification on a code before billing.

It’s also important to remember that even if billing by the physician or nurse practitioner is outsourced to an outside billing service or a trained billing clerk that is onsite, it is the person on whose professional licensure the care and billing are based is the person that is responsible for accurate billing.  A nurse practitioner or a physician still has to learn something about reimbursement and coding.

Any health care professional who knowingly cheats on coding to enhance their reimbursement, can be guilty of both civil wrongs which is considered a “breach” of the insurance contract, and it’s considered a crime, which can lead to costly legal fees.  Billing fraud can also result in having to return part or all of the wrongly paid money, fines, loss of their professional license and possibly serving time in prison.

How do fraudulent claims get noticed?  There are several ways.  Some insurance carriers have fraud detection software which they use to analyze data.  When unusual billing patterns are discovered, they initiate an investigation.  Sometimes it is the patient that is complaining about the amount of the bill or services that were billed.  Employees have revealed on their good conscience of fraudulent practices and don’t want to be part of the scheme or it violates their own ethics.  Bottom line is physicians or other health care providers who engage in this type of behavior have been costly and have led to them no longer being able to practice in the medical field.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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Electronic Medical Records Part II

As was discussed in part one of this article the risks of using the technology of electronic medical records shows many things that physicians should be aware of and also how to reduce legal risks.  We will continue on with this article with five other ways to reduce these risks.

6.  Physicians should make sure to sign off the record or log out of the system

This practice is extremely important so that if a physician does not sign out and another physician continues under his or her log in name.  This can create a problem because the bill could be submitted under the wrong physicians name.  If this were to happen an insurance company can ask for a refund of payment if a medical record is submitted during an audit.

7.  Understand how the system records who is accessing and writing in the record

There should be a system in place where if one is accessing the record but after a period of inactivity an automatic time-out occurs.  If a physician needs to make changes or add to a record this should be done at the end of the day but there should be a time period in which the record should lock.  In the case of changes being made, a new entry should be noted and it should be clearly written as an addendum to the record with the date of which this change or addition was made, the reason why the change or additional information was added and also at the end of the entry should be an electronic signature to verify the person who made the changes.

8.  Print out a note from time to time to be sure your entries are in your name and record the time of the medical record entry

 The past some physicians have had the habit of entering in the patients record in the era of pen and paper method, to record things that haven’t happened yet.  One example could be that a physician records a date of a cesarean section but that actually hasn’t happened yet.  So this would have to be entered as a notation with the actual date of when it was entered instead of in the future.

9.  Make sure that only appropriate staff members have access to the records

There should be a protocol in place in case of a security breach from a staff member or other person.  There should be a password that is protected when the person or persons that have authorization to log in.  Having an automatic sign-out feature is also a protection in case the physician should forget to log out.

10.  Protect records from inappropriate viewing by setting up screensavers and require a password for reentry

Having this feature helps if ever the laptop or computer is left in a room unattended.

Marina Hall is a Certified Medical Reimbursement Specialist (CMRS) and founder of MariAnn Medical Billing Service. To read a full “Interview with Marina Hall” visit her website at

Click here to read testimonies regarding MariAnn Medical Billing Service

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