Give Your Documentation an Easy Upgrade
One of the easiest, often overlooked aspects of documentation is the use of recognized Outcome Assessment Tools (OATS). These condition-specific questionnaires are one of the few pieces of documentation that a patient will fill out on their own. So valuable are these tools to a third party payer that they often place as much emphasis on the scores from the OATs as they do your own notes.
OATs are actually a functional assessment of a patient’s ability to perform activities of daily living (ADLs). Regardless of pain level, ADLs that are impaired by the patient’s condition become your rationale for the care that insurers are willing to pay for and become the primary motivators to patients for completing their care plan.
Implement the initial OAT at the start of the patient’s care plan and update it at each subsequent re-examination. Use your OATs in two ways: first, document the initial deficit percentage in the treatment plan, using it as a measurement of treatment effectiveness with a long-term goal of getting to 10% deficit or better. Track this throughout care.
Second, record and specify individual ADL deficits the patient has using these factors to identify your short-term functional goals for care. Once the patient has achieved maximum improvement for all functional deficits, transition them from active treatment into wellness/maintenance care. This simple upgrade to your documentation will yield amazing results.
Do You Have a 2017 Intake Form?
If you’re relying on a skimpy intake form from years ago, you’re probably not collecting the necessary information you need to get paid what you deserve.
Inadequate information here, is a signal to insurers that 1) you don’t understand your documentation obligations, 2) you can’t defend the medical necessity of your care, 3) you’re fair game for reduced reimbursements and, 4) easy pickings for a post review audit.
Your daily notes may be flawless, but can you prove functional improvement?
A subset of our complete paperwork system, the Intake and Reevaluation Forms are the crucial, patient-facing forms that collect meaningful use, activities of daily living and other critical data that dramatically improve your chances of being fully reimbursed for your care.
There’s still abundant insurance reimbursement available, but you must collect the data that third parties want and expect. And it all starts on the first visit.