Did you know that even one insignificant error in an EHR can be quite costly? There is no doubt about the efficiency of an Electronic Health Record (EHR)—the digital version of a patient’s medical chart. However, we cannot deny the possibility of errors due to human oversight and technical limitations.
Mistakes in data entry, vague or incomplete medical notes, workflow, and integration problems can lead to significant billing issues and consequences, including payment delays and even potential patient safety risks. So, how can you fix these issues before they become a major problem? Let’s find out, but first, let’s explore the most common EHR mistakes.
Most Common EHR Errors
From providing real-time information access to improving coding and documentation accuracy, EHRs have simplified medical billing. That’s why nearly 88% of office-based physicians (9 out of 10 doctors) have adopted this technology. While EHR systems are critical for independent practices, they are not immune to errors.
Many doctors and practices face customization, design, and configuration challenges with their current EHRs, leading to basic mistakes. Before moving on to the best corrective strategies, you should understand the following common EHR errors.
Incorrect Data Entry
This is the most basic and most common EHR mistake. Did you know that US healthcare providers make approximately 1.25 million medication errors every year? The main reasons? Mistaken identity or prescription errors due to typos.
Mistyped or incorrect patient information, such as name, D.O.B., and insurance details, can result in significant billing and healthcare issues. Consequently, this can lead to payment delays and medical mistakes like inappropriate dosages.
Outdated Information
This is another common mistake. Healthcare providers often rush through their administrative tasks and fail to update every patient’s record in the EHR system after every encounter, which includes new diagnoses, treatment progress, or allergies. As a result, they recommend the wrong treatment plans due to outdated information, putting their patients at risk.
Inconsistent Data
Around 69% of healthcare providers experience EHR interoperability issues. If you are unfamiliar with this word, it simply refers to the ability of multiple EHR systems to exchange information. For instance, a patient visits a doctor at one hospital but later consults a specialist in another state. The specialist would need access to the patient’s EHR to review their medical history.
A lack of interoperability can lead to inconsistent patient information and discrepancies, resulting in missed charges, medication errors, redundant tests, and unnecessary expenses.
Duplicate Data
Human oversight can also result in duplicate entries. While this might seem like a minor problem, redundant patient data, such as tests, treatments, or diagnoses, can lead to overbilling.
Incomplete Documentation
Missing or incomplete patient information, along with illegible or vague clinician notes, can create significant confusion. These errors add to the frustration of healthcare providers and billing teams. Simply put, they make it challenging to apply the correct billing codes or justify the medical necessity of the performed services to insurance companies.
Identifying the Need for EHR Corrections
EHR corrections are essential for several reasons, with patient safety being the most critical. Mistakes in Electronic Health Records impact everything, from billing accuracy to your reputation. However, spotting these errors is not an easy task. It requires a collective effort, including routine reviews and cross references with other health records.
We will discuss how to address these errors in detail in the next section. But first, let’s explore the reasons why EHR corrections are essential.
To Reduce the Risk of Harm
As mentioned, patient safety is the primary reason for recognizing the need for EHR corrections. Simple mistakes in recording patient information, such as missing allergies, incorrect medications, and outdated medical records, are the leading causes of misdiagnoses and inappropriate treatments.
This often leads to adverse drug reactions and, in extreme cases, even death.
Maintain Regulatory Compliance
According to federal standards, healthcare providers must protect sensitive patient information. As such, they are required to comply with HIPAA regulations, which also include maintaining accurate patient records.
Therefore, providers must promptly spot and correct EHR errors to maintain billing and medical compliance.
Improve Billing Accuracy
EHR mistakes can also jeopardize your cash flow. Incorrect or duplicate patient information leads to inaccurate coding, resulting in claim denials, underbilling, or reimbursement delays. You can improve billing accuracy and clean claim rates by identifying these errors before claim submission.
Avoid Legal Risks
Error-free billing can protect you from long-term legal consequences, including lawsuits and heavy fines. EHR-related mistakes, especially those that compromise patient safety, can compromise your medical license or practice. Therefore, you should conduct regular reviews to spot and address these errors.
Improve Patient Retention
Identifying and correcting EHR-related errors can also help build strong relationships with your patients. Maintain accurate and coordinated patient information to improve patient care and increase retention.
How are Corrections Made to EHR Errors?
Your EHR system should always work in your favor. If you want to accelerate your revenue cycle, follow this step-by-step guide to correct EHR errors:
Identify the Mistake
The first step is to identify the EHR error. You can do this in three ways: routine audits, staff feedback, or patient input. The ideal method is to regularly review patient records to spot inaccuracies, such as incorrect dates, vital signs, medication dosages, data inconsistencies like conflicting diagnoses and treatments, or missing details like lab results and insurance status.
Additionally, you should also encourage your billing staff to report whatever EHR errors they encounter during their tasks. The third way is quite unconventional but effective. Many practices show patients their medical records during follow-up visits to catch discrepancies.
Review & Follow Established Rules for Corrections
Every healthcare organization has set rules for EHR corrections, commonly known as amendments. These amendment procedures usually align with HIPAA’s standards to avoid legal risks or billing complications. Therefore, review your practice’s policies before accessing the EHR and making any corrections.
Access the EHR & Make the Necessary Correction
The next step? Access the EHR to make the appropriate correction. Instead of deleting the original data, create a new entry to explain the correction. This is important for auditing purposes.
Remember that only authorized individuals, also known as covered entities according to HIPAA, can access the EHR within a healthcare organization. But only a few can make the necessary corrections. These are usually healthcare providers directly involved in the patient care. So, if you are not that designated individual, request the authorized person to correct the mistake.
Document the Correction
This is the most important step in this entire process. Document everything, including the identified error’s nature and the reason for correction for future context. The best thing about most EHR systems is the automatic timestamp. It means that you no longer need to document the correction time manually for transparency.
Inform Relevant Parties
Communication can help you avoid unnecessary confusion. Therefore, you should notify everyone involved, including the clinician, billing team, and administrative staff, about the EHR correction.
This is important because even if they can access the patient’s records, they may not be aware of specific amendments and might not verify the data before filing claims or recommending medications.
Cross-Check Everything
Last but not least, review and verify that the corrected information is reliable. In simple words, validate the information to make sure it aligns perfectly with other parts of the patient’s medical records and complies with legal and regulatory requirements.
Avoid Future Errors
While EHR errors are not entirely avoidable, you can take some precautions to minimize them. For example, provide regular training sessions to your staff to improve data entry and documentation accuracy.
Additionally, identify and address the most recurring mistakes to avoid the same occurrences. Lastly, use your EHR systems’ advanced features, including automated checks, to catch potential errors in advance.
Significance of Accurate EHR in Medical Billing
Electronic Healthcare Records have transformed healthcare from dealing with a stack of paper records to accessing real-time information. In simple words, we can say that EHRs have simplified workflows and improved efficiency by providing a centralized platform.
Through instant data entry and seamless documentation, healthcare providers can now achieve better financial and health outcomes. Accurate EHRs, specifically, play a key role in medical billing, reducing claim denials and compliance issues. Here are some factors highlighting the significance of maintaining EHR accuracy.
Improved Clinical Decisions
One of the key benefits of accurate patient records is the ability to make better clinical decisions. This means that with improved data accuracy, doctors can prescribe correct medications and offer high-quality patient care.
Fewer Claim Denials & Payment Delays
Accurate records can also help you achieve clean claim rates, leading to faster approvals and reimbursements. They also simplify the pre-authorization process for costly treatments or procedures, reducing care and payment delays.
Minimizes Financial Risks
Another key benefit of maintaining accurate patient records is improved cash flow. Accurate EHRs help you avoid over- and underbilling, reducing the risk of legal penalties and financial losses.
Final Word
To summarize, we can say that Electronic Health Records are the backbone of today’s healthcare organizations. They facilitate the effective delivery of healthcare, smooth billing processes, and faster approvals. However, they are not immune to mistakes due to human involvement.
Mistakes in EHR are quite costly, impacting everything from patient care and billing accuracy to your reputation. The good news? You can identify and correct these mistakes through proactive measures like routine medical billing audits and staff training. In short, you can transform your practice and achieve immense growth by following the best practices and investing in a certified EHR system.
