Paperwork Done Wrong, Done Right

I was visiting a doctor's office recently and a member of his staff brought a stack of forms to his private office and laid them on the doctor's desk. She informed him he needed to complete the forms for patients and a few third parties.

The forms were typical of paperwork in any practice, chiropractic or medical. The snag was the paperwork went beyond the paperwork required for normal patient care and reimbursement. The doctor's response was one of disgust. This reaction is also typical in any practice, chiropractic or medical.

The doctor quickly signed the forms that were for simple requests. These included forms for missed work days, work removal, a note for a student who missed school and a handicap parking permit. He sorted through the remaining forms, removing one for a worker's compensation case, a phone message from the attorney requesting a letter summarizing the personal-injury case, a disability application and phone message from a patient's daughter.

He handed the selected forms back to the staff member and said he was not going to complete them. He told her to inform the involved parties and tossed the remaining paperwork back on his desk.

While much of the paperwork discussed here is usually viewed by health care providers as being above and beyond routine paperwork, patients and other involved parties view it as part of a doctor's job. Patients and other requesting parties become frustrated, if not mad, when paperwork they request is not completed immediately or by a specific deadline. How are you handling the following paperwork issues? There's a right way and a wrong way.

Work-Related Notes

Work excuses can be vital to a patient's employment security. The "note from your doctor" is important in establishing an absence should be excused. Job security means security of insurance coverage, personal health insurance and/or worker's compensation coverage. It also influences the patient's ability to pay deductibles and co-pays. In short, the simple note helps maintain the patient's access to health care.

If paperwork (a note) is necessary to remove a patient from work, the note should be very specific regarding the duration of the absence and the return-to-work date. If the absence is not related to a worker's compensation injury or illness, personal and health information must not be included.

If removal from work is due to a work injury, health information in the note should be limited to information related to the worker's injury.

Modified Duty Orders

Modified duty assignments (formally known as light duty) require greater detail than notes for work absence and removal. Paperwork for modified duty assignments can be problematic if you are not familiar with the patient's occupational responsibilities. This can be avoided if you ask questions about social and occupational activities during the patient's initial evaluation and management. If this was not accomplished initially, you should question the patient about occupational responsibilities prior to specifying modified duty assignments.

Worker's compensation cases managers often accompany patients during office visits. They always request the patient's records and need "their" paperwork completed. The extra person in the room and extra questions slow down the flow of the office. The patient is annoyed and the additional paperwork is, as always, unwelcomed by the provider.

The doctor I was visiting returned the paperwork to the case manager because he felt the day-to-day records should suffice and the case manager should have taken notes during the visit. Unfortunately, worker's compensation carriers, like most carriers, may only reimburse the doctor if the documentation they require is provided in the format requested.

School-Related Notes

Most notes for missing school or removal from school are similar to notes related to missing work or removal from work for a few days. Circumstances are a little more complicated if a note is required for removing the student from athletic activities. You must be firm in your decision to remove the student and be aware that you may have to deal with "Little League parents," overzealous coaches and disappointed students. As always, notes cannot contain personal health information other than what you have written permission to release.

Attorney Requests

The phone request for a letter from the attorney is tricky. If you know and trust the attorney, you may provide the letter and bill the attorney. If this isn't the case, you should never start, complete or send a letter of this nature to an attorney without a letter of request from the attorney. This holds true for full case reports, too.

Attorneys often have their staff call to request a letter / report or have the patient ask for one. You may experience problems collecting fees in these situations. An attorney may later claim that your staff misunderstood the request and refuse to pay. Once the attorney has the report, you have minimal leverage. Obtaining requests for letters / reports in writing helps avoid "miscommunication" and obtain payment.

Avoid writing reports prior to receiving payment. If the report is written prior to payment and placed in the patient's file, it is part of the patient's records. A simple records request provides the report to anyone requesting the records, including the attorney.

Disability Applications

Disability applications can be tedious, but they are very important to the patient. The applications are directly linked to the patient's finances. Disability benefits are a lifeline. The doctor who refused to complete the disability application hurt his patient by doing so. The state where the patient resides requires three doctors be in agreement regarding the patient's disability before benefits are granted. The patient may have been left with minimal, if any, source of income.

There are exceptions here. A few patients pursuing disability status do not meet the qualifications necessary to obtain disability status. In these cases, you must be honest with the patient and inform them prior to the completion of the application.

Handicap Parking Permits

Handicap parking permits can be temporary or permanent. Both types are easy to obtain with a doctor's signature. They are very beneficial for the patients who need them. Unfortunately, they are often issued indiscriminately. Nothing is more annoying to many people than a person with a handicap parking permit who does not need one.

Family Requests for Patient Information

The last paperwork request the doctor received was through a phone message from a patient's daughter. The daughter wanted a letter summarizing her mother's health and course of care. This request cannot be fulfilled without the patient's permission. A HIPAA wavier, guardianship or power of attorney must be in place in order for the daughter to receive the information.

Denial of the requests due to a lack of permission can quickly create animosity. It is often difficult to deal with aging parents. Delays in obtaining needed information do not help, but you and your staff must stick to the rules. Consequences can be drastic if privacy rules are not followed.

In general, paperwork that does not directly relate to patient care and reimbursement often allows outside sources to place unwanted requirements and deadlines on the practice. However, it is part of the job and practices must develop a method for dealing with additional paperwork. Planning helps control the situation and everyone must remember that ultimately, documentation is for the patient's benefit.