Documenting financial information

Feb. 1, 2004
Financial information should not be enmeshed with the clinical portion of the patient record. In the event the patient exercises the right to inspect the clinical record and/or obtain a copy of it, only the clinical information should be available.

Tom Limoli Jr.

Financial information should not be enmeshed with the clinical portion of the patient record. In the event the patient exercises the right to inspect the clinical record and/or obtain a copy of it, only the clinical information should be available.

If the record is entered into evidence as part of a legal proceeding, financial information has been known to have an adverse effect. Only financial data for the active treatment plan need be included in the treatment folder.

Use separate file

The returned predetermination, hard copy of the claim, signature-on-file cards, explanation of benefits forms, laboratory prescriptions, specifics of individual financial arrangements, as well as copies of checks from both the patient and third-party payers, should be filed away in a separate, logged filing system. This filing system should be indexed, based upon the completed (treatment and financial) series of visits. In other words, financial and other nonclinical data concerning completed treatment plans need not clutter and dilute the integrity of the patient record.

First-visit date

With the concept of first-visit date for the current series as background, a system is easy to implement. When each individual treatment plan is limited or divided into a series of visits, the paperwork falls right into place.This system of separating financial and treatment records serves a number of purposes:

1) The tools for tracking all those open and incomplete treatment plans are now at your disposal.

2) The patient record is no longer cluttered with nonclinical financial data.

3) Closed and completed treatment plans — with all the claim forms and EOBs — can be systematically filed away for storage.

4) In the unforeseen event of litigation or malpractice, financial data has a greatly reduced possibility of complicating any quality-of-care issue.

Begin with existing records

The process of initiating the use of financial folders is simple if you start today. Begin with that day's patients who are scheduled for either an initial or periodic oral examination. What is the result of that examination and what additional findings or recommendations have been made to improve the patient's oral health?

Are Mr. Smith's old amalgam fillings, with open-ditched margins, ready to be replaced? Is Mrs. Jones still taking out her lower partial when she eats pork chops? How about the banker's six anterior teeth that are not decayed or fractured, but look horrible? These are the patients you need to start with in your financial documentation.

In this day of electronic claims, attachments, and automated records, there is no substitute for accurate diagnostic, treatment, and financial documentation. To involve yourself in this electronic age — without a realistic perspective of basic recordkeeping — can truly be a waste of valuable resources!

Tom Limoli Jr. is the president of Atlanta Dental Consultants and the editor of Dental Insurance Today, a bimonthly publication that addresses third-party reimbursement in the dental office. He also is the author of Dental Insurance and Reimbursement Coding and Claim Submission. He can be contacted by phone at (404) 252-7808. Visit his Web site at www.LIMOLI.com.

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