The impact of regulations and compliance on billing and liability has created inefficiencies and confusion for many first responders. First, there’s HIPAA compliance and making sure you’re protecting patient information and securing your data. Next, there’s medical compliance with the Health Care Reform Act, which now defines what procedures and medications information needs to be included in your PCRs.
Finally, there is the Affordable Care Act, which is a moving target of regulations and ever-changing requirements. Are restrictions and programs going to go away, pull back, or are they going to get worse? Only time will tell.
So as compliance and liability continues to exist in a constant state of change, many service providers have realized that using an ePCR system is the quickest path to lower the risk of liability in three major ways:
- Standardizing data
- Structuring reporting
- Providing supporting documents
Standardizing data
An EPCR standardizes required data, ensuring a medic completes all fields required for NEMSIS and NEMSIS 3, which requires much more data. Many EPCRs have built-in NEMSIS validation, integrated data dictionaries, and are multi-state compliant, eliminating chances for errors and increasing accuracy. Standardized data allows the system to be fully trackable and auditable through searchable fax and user logs and monitoring all CQI and billing actions. Standardizing data ensures all information and data needed for patient care is complete and compliant, further securing a reliable system and reducing liability.
Structuring reporting
An EPCR allows you to structure your reporting for insurance providers, billers, and state requirements that require all medical information to be presented in a certain format. Features such as highlighted required fields, and built-in validation ensures you’ve entered all information required and met the state standard.
In addition, some EPCRs have integrated forms libraries, which digitizes all paper forms, and maps them to fields in the EPCR, so you don’t have to enter data more than once. Furthermore, an EPCR captures all signatures, including your authorization of care, your transfer of care, and your refusal of care – information required for Medicare payment and to ensure you’re maintaining compliance and protecting your liability.
Finally, an EPCR can update changes to federal and/or state regulations, as they change often. Changes and updates made to the system alert you if your claim is liable to be rejected because of missing, updated standards, allowing you to correct or add the updated information before you file it. So, having an EPCR system allows you to stay current with all regulations, rules and coding, this reducing your risk of liability.
Providing supporting documents
Many EPCRs have the ability to scan extra documents, such as crime scene photos, accident scene photos, insurance cards, face sheets, rhythm strips, etc. Ultimately, this information is required and an EPCR gives billers the ability to see additional items outside of the report, such as forms and pictures, so they can comment or request amendments, avoiding liability and Medicare and Medicaid issues.
In this digital age, patient care reports are being converted to electronic reports because they can be more standardized, structured, and in-depth. An EPCR system can enhance patient care and make it more efficient and effective through providing standardized records that cover everything needed for regulatory compliance. Keeping digital documentation of PCRs ensures for better communication, faster processing and, more importantly, reduced liability.