18 Nov Medical Record Compliance: Ensuring Accuracy and Security

Medical Record Compliance: Ensuring Accuracy and Security

Medical recordkeeping is both crucial and complex. Records must be accurate, up-to-date, and consistent while adhering to preset federal and local reporting standards. Medical record compliance ensures patient documentation is secure and understood across providers, physicians, clinics, and reporting systems. 

As such, failure to comply with reporting standards not only affects patient care quality—it can also lead to legal repercussions for healthcare providers.

From major federal laws to state-level variations, understanding and following medical reporting standards keeps providers compliant and maintains the legality of their operations. 

What Is Medical Record Compliance and Why It Matters

Medical record compliance means adhering to the legislative guidelines governing healthcare documentation. At a federal level, reporting standards are set by the Centers for Medicare & Medicaid Services (CMS) and further detailed in the Health Insurance Portability and Accountability Act (HIPAA). 

In addition to national standards, state-level laws likewise govern how physicians and care providers create and keep medical records. There are also program-specific standards certain providers must adhere to, especially for those receiving public funds.

These regulations are critical in medical reporting. Without recordkeeping standards, medical documentation would be:

• Inconsistent and potentially unintelligible from physician to physician
• Incomplete with missing details about patients’ conditions
• Disjointed, disorganized, and difficult to understand

Reporting standards ultimately ensure medical documentation follows preset rules, making patients’ files quick to assess and understand as they move between providers. 

Adhering to medical recordkeeping standards likewise ensures:

• Patient privacy – By their nature, medical records contain Protected Health Information (PHI). This sensitive data is the privilege of patients and their care providers. Recordkeeping regulations uphold patient privacy by levying penalties on providers who share or leak PHI protected health information.

• Reporting accuracy – With no reporting standards, physicians would keep medical records in ways that may not make sense to other providers. Complying with recordkeeping regulations ensures patient records are understandable across the medical industry.

• Legal defensibility – HIPAA and other key legislation not only offer guidelines for medical recordkeeping, but also outline the penalties providers can incur if they fail to follow regulations. Medical record compliance leaves providers with solid legal standing should they encounter a lawsuit or other targeted litigation.

The first step to compliance is understanding how regulations affect healthcare providers. So, what do HIPAA and other key acts say about medical recordkeeping?

Key Regulations Governing Medical Record Compliance

HIPAA is the main legislative act governing healthcare practice in the US. It’s primarily concerned with patient privacy and includes regulations on:

• Patient access to PHI – It’s mostly prohibited to share a patient’s protected health information (PHI) without their consent. On the other hand, patients have an irrefutable right to access their own medical records and PHI. Providers must comply with most patient requests to view their own medical documentation.

• Exclusions from PHI access – While patients generally have a right to their own PHI, there are exceptions to the rule. Patient PHI access excludes psychotherapy notes and any records slated for use in civil, criminal, or administrative proceedings.

• The right to share patient records – Generally, healthcare providers can’t transfer or display patient records without explicit consent. They can, however, share health information for billing, treatment, and operational purposes without prior patient permission.

In addition to HIPAA, the Health Information Technology for Economic and Clinical Health (HITECH) Act also covers medical record handling and compliance. It’s essentially companion legislation that strengthens HIPAA protections and increases fines for potential violators with:

• Four categories of violations
• Four penalty tiers that significantly increased fines from previous levels
• A $1.5 million maximum penalty for wilful non-compliance with HIPAA standards

The CMS also offers its own rules on medical documentation, particularly in regard to its agency’s access to records for insurance purposes. They stipulate:

• The kinds of documents—including doctors’ notes, treatment plans, and lab tests—they can request to confirm a patient’s coverage eligibility

• The agency’s right to deny coverage for incomplete or illegible records

• Authenticity requirements for document submissions, such as doctors’ signatures

State-level agencies and programs may also have their own medical record compliance guidelines. These can vary from HIPAA and CMS standards, but healthcare providers and law firms—especially those operating as a covered entity or business associate—are subject to them nonetheless. 

Similar to defying HIPAA, failure to comply with state-level regulations can result in hefty penalties. Blatant violations can even push punishment beyond civil fines and result in potential criminal charges for the perpetrator. 

So, while adhering to recordkeeping regulations can be challenging, it’s necessary to maintain legal compliance.

Common Compliance Challenges in Medical Record Management

Despite the importance of medical record compliance, a few common issues can make managing medical documentation more difficult. These include:

• Incomplete records – Reporting standards require Attending Physician Statements (APSs) to detail all of a patient’s health information, but records are often left incomplete. Whether it’s an unfilled page, a missing signature, or another minor error, public insurance programs like Medicaid can deny coverage for incomplete records.

• Data breaches – HIPAA requires providers to safeguard protected health information, but data breaches are still common. Following a data breach, the provider must inform the patients, the Secretary of breaches, and the media (if more than 500 individuals are affected).

• Delayed updates – Patients are entitled to receive their PHI and other medical records within 30 days of a request. Insurers, lawyers, and healthcare organizations may have even shorter timelines for receiving records—but providers don’t always meet these deadlines.

Human error is also a persistent problem with medical recordkeeping. Certain providers may also not be up-to-date on compliance standards, leading to inconsistent documentation practices across the medical industry. 

Working with Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) can also lead to compliance issues. Both of these kinds of records contain protected health information, which is a provider’s duty to safeguard. However, insurers, lawyers, and other healthcare organizations may make legitimate requests for these documents, which can lead to confusion over when to share or sequester records. This issue is amplified on record-sharing platforms, where it’s not always clear who has access to specific files. 

Best Practices for Maintaining Compliance

Maintaining secure data storage practices is key to ensuring medical record compliance. HIPAA requires organizations that handle and store medical records electronically to:

• Carefully monitor the receipt, transfer, and removal of digital storage devices—including wiping PHI protected health information before reuse or disposal

• Implement secure transmission procedures for all data transfers

• Limit information access to authorized personnel

• Utilize authentication methods to securely verify authorized personnel

• Maintain role-based usage policies that limit information access based on the user’s position in the organization

• Install auditing programs to monitor any information systems that store, transfer, or utilize PHI

• Train all workers on medical record compliance, system usage, and PHI security policies

Modern electronic systems and automation processes make storing, organizing, and sharing medical records much simpler than in the past. What’s more, HIPAA’s guidelines make using these systems more secure for patients, healthcare providers, and other organizations. 

Electronic storage systems also improve medical recordkeeping accuracy as they offer standardized documentation to work from. By standardizing documentation across different healthcare organizations, records are more universally understandable. Then, when it’s time to read, review, or retrieve them, there’s less confusion over their contents and meaning.

The Role of Retrieval Partners in Compliance

It’s not only essential to adhere to established regulations during medical documentation—it’s also crucial when requesting records. Medical record retrieval services help healthcare organizations, law firms, insurers, and other parties maintain compliance while obtaining patient information. 

Securing medical records can be a drawn-out process, and successful requests often require time-consuming paperwork. Using medical record retrieval solutions makes the process:

• Faster – Individual record requests often take 30 days or more to process. Retrieval partners lean into their relationships with major healthcare providers to obtain records faster.

• More secure – Retrieval partners specialize in obtaining records through secure, private channels to mitigate the risk of hacks or leaks of protected health information.

• Complaint – With trustworthy partners offering fully compliant request portals, retrieval services make it challenging for organizations to stray from HIPAA and other regulatory standards.

Retrieval partners also lower the administrative burden on law, insurance, and healthcare teams by taking care of submissions and follow-ups. Medical record retrieval for lawyers delivers evidentiary-ready documentation with keyword, date, and phrase searchability. Meanwhile, medical record retrieval for insurance companies leverages dedicated account management to expedite claims toward underwriting and evaluation. And, for healthcare organizations that are already strapped for time, record retrieval partners free up employees to focus on more strategic work.

American Retrieval is the nation’s most trusted medical record retrieval partner. With trained industry experts and an intuitive, regulatory-compliant request portal, American Retrieval makes adhering to medical record release standards quick, easy, and efficient.

Building a Culture of Compliance

Medical record compliance requires adherence to HIPAA and CMS standards regarding data storage and security. Strong compliance practices safeguard protected health information, make records more useful to medical teams, and keep organizations legally defensible.

As such, it’s important to constantly review your organization’s compliance policies and partner with industry experts—especially when it comes to medical record requests. Retrieval partners like American Retrieval not only keep your requests compliant, but they also expedite release timelines and remove administrative burdens from your team. That means you can focus on reviewing and using medical records, rather than requesting them.

Partner with American Retrieval to strengthen your medical record compliance process today.

Sources: 

Centers for Medicare and Medicaid Services. Medicaid Documentation for Medical Professionals. https://www.cms.gov/medicare-medicaid-coordination/fraud-prevention/medicaid-integrity-education/downloads/docmatters-medicalprof-factsheet.pdf. 

United States Department of Health and Human Services. Summary of the HIPAA Privacy Rule. https://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html. 

United States Department of Health and Human Services. Individuals’ Right under HIPAA to Access their Health Information 45 CFR § 164.524. https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/access/index.html. 

American Medical Association. HIPAA violations & enforcement. https://www.ama-assn.org/practice-management/hipaa/hipaa-violations-enforcement. 

Centers for Medicare & Medicaid Services. Complying with Medical Record Documentation Requirements. https://www.cms.gov/files/mln909160-complying-with-medical-record-documentation-requirements.pdf. 

United States Department of Health and Human Services. Breach Notification Rule. https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html.