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Fam Pract Manag. 2002 Jul-Aug;9(7):56.

When patients request their records

Q

When a patient requests “all” of his or her medical records, does that include copies of medical records from other doctors, reports of findings from specialists the patient has been referred to and lab results that were ordered by other physicians?

Yes. The Health Insurance Portability and Accountability Act’s (HIPAA’s) privacy rule, which goes into effect in April 2003, grants a patient access to all of the information in his or her medical records. The rule states that “an individual has a right of access to inspect and obtain a copy of protected health information about the individual in a designated record set, for as long as the protected health information is maintained in the designated record set.”

What is a “designated record set”? According to the HIPAA privacy rule, it is “a group of records maintained by or for a covered entity that is: (i) the medical records and billing records about individuals maintained by or for a covered health care provider; (ii) the enrollment, payment, claims adjudication and case or medical management record systems maintained by or for a health plan; or (iii) used, in whole or in part, by or for the covered entity to make decisions about individuals.” The rule defines “record” as “any item, collection or grouping of information that includes protected health information and is maintained, collected, used or disseminated by or for a covered entity.” The term “health information” is defined as “any information, whether oral or recorded in any form or medium, that (1) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university or health care clearinghouse; and (2) relates to the past, present or future physical or mental health or condition of an individual, the provision of health care to an individual or the past, present or future payment for the provision of health care to an individual.”

To find answers to specific questions about HIPAA’s privacy rule and its interpretation in your practice, check with your legal counsel. For other information about HIPAA, go to the FPM HIPAA Topic Collection or http://www.aafp.org/advocacy/informed/legal/hipaa.html.

Reasonable bad debt

Q

How much bad debt should a two-person family practice reasonably expect per year?

It depends on how you define a bad debt. When you receive only 80 cents on the dollar from a managed care contract, the 20 percent is not a bad debt; it is a contractual write-off. A true bad debt is where the patient is unwilling or unable to pay. This type of debt is pretty rare and typically amounts to only about 1 percent of billings. In hard economic times or economically depressed communities, bad debt can run as high as 2 percent to 3 percent of total billings. Keep in mind that bad debts are nearly zero when you make a practice of collecting co-pays and deductibles at the time of service.

Including the correct diagnosis on a claim

Q

When an insurer denies a claim based on a diagnosis code that was submitted incorrectly (e.g., the diagnosis code suggests that the study wasn’t medically necessary) and we can’t get the hospital or medical group administration that submitted the claim to correct it, what recourse do we have? This happens often to our patients, and they usually decide to pay rather than face credit bureau problems, but that doesn’t seem right.

It depends on where the problem originates – the hospital or the physician’s group. If the claims are being submitted incorrectly by the hospital, this is primarily a customer-satisfaction issue, where the customers are the referring physician and the patient. Why would a physician continue to use a service that is not customer-friendly? If the providing hospital is in the network, it may be possible to fashion some argument related to inappropriate denial and patient grievance. It may also be possible to make a complaint to the state regulatory authorities. On the other hand, the physician may simply need to talk to someone in a high-level supervisory position at the hospital about the problem.

If the claims are being submitted incorrectly by the physician’s own medical group, that is a different kettle of fish. The physician should go directly to the administrator with a written complaint and evidence of the problem. It could be that the group is intentionally trying to garner better payment (if the insurer pays less, the patient pays more in cash). However, this is more likely a lower-level problem resulting from administrative personnel simply doing the easy, familiar thing.


* Denotes member of FP Assist, the AAFP’s online clearinghouse for consultants and attorneys.


 

Copyright © 2002 by the American Academy of Family Physicians.
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