Change is Good (And Happening Now)
Delta is requiring proof of treatment in the form of clinical notes, which means an easier, more expedited insurance claims process for both you and us here at eAssist. To be more specific, Delta says:
“Narratives as documentation are not considered legal entities nor are they contemporaneous in nature. The patient record/clinical notes are considered a legal document and are contemporaneous. The only acceptable legal written documentation for utilization review are the contemporaneous treatment notes.”
These changes were first put into practice in 2018, with an emphasis on real-time compliance for 2019 and consequences for lack of adherence in 2020. There is no better time than now to familiarize yourself with what’s required so that you can get paid on time and in full.
What’s Required of You
Being both specific and complete in your notes is essential for efficient processing. This includes everything that happens or is utilized in treatment from patient records, such as:
- Periodontal charts
- Anesthesia records
Outside of these examples, eAssist has referenced American Dental Association (ADA) guidelines in order to give you a better idea of what you need to put in your clinical notes:
Why It’s Important
Since all of this information is vital to your patient, it is imperative that you include their personal information in a way that ties all of the treatments given together, making it easy to reference for both yourself and the insurance company so you can get paid. By keeping things complete and clear, there won’t be any room for insurance companies to deny your claim based on a lack of information or shoddy note work.
As well as this, eAssist utilizes your clinical notes in order to maximize the efficiency of getting claims paid out fully. If you’re not telling us something, or you forgot, we won’t be able to fix it until you’re already making up for lost time and money. This makes it imperative to implement practical policies for your dental practice employees to utilize in getting their work done properly the first time.
Ensuring that each of your employees is aware of their new duties is crucial to long term implementation success for clinical notes. Some things you can do in order to make the transition easier include:
- Take stock of patient personal records and dental history so that everything is easy to reference when needed. Create colored tabs for each section that make searches a breeze, and use keywords for any scanned documents to find what you need regardless of what department you’re in.
- Maintain multiple/redundant record keeping in case of hard drive loss, fire, or other accidents. Photocopy or scan important documents to keep on a secure server for easy retention.
- Encourage employee communication outside of their immediate responsibility, so that there are no misconstrued note-taking or irreverent information being added that could potentially deny your claim due to discrepancies.
What eAssist Will Do For You
The clinical note requirement is being enforced by both insurance companies outside of Delta as well as us here at eAssist. Our goal is to get you paid 100% of what you’re rightfully owed, each time. If your practice is falling behind on implementing clinical notes over narratives, the claims we submit will be denied due to a lack of credible information.
Delta themselves even inform us: ‘There is a general rule in a court of law that states that “if it is not in the clinical notes, it did not happen”.’ Without efficient processing, you’re not only losing time, but also money. To prevent this, clear and concise implementation of the aforementioned duties should be our number one goal working together into 2020.
Dental Billing Tips and News for Pros; Edition #143