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3 Tips for Developing a Medical Records Retention Policy

January 16, 2018

Medical Records Retention PolicyState and federal regulations often require medical practices to retain billing records for a minimum period of time. However, these practices can not retain every piece of information they have forever because they will eventually run out of space. Many practices still keep paper records, and those that have made the transition to a paperless environment rarely spend the time needed to convert their existing paper records into electronic format.

A plan that specifies the retention period of each document type is therefore essential for all medical practices. The retention period of these records must be at least equal to legal requirements. The retention plan must also describe how and where these records should be stored as well as the procedure for destroying documents that are no longer needed. This article discusses the general points that medical records retention policy should cover, which you can then use as a template when to develop your own policy.

Overview

Each department in a healthcare facility may need a different retention policy since they may handle different types of records. A practice’s compliance committee should also research, review and approve each retention policy before implementing it. The practice’s C-level executives should also sign off on the retention policies to ensure those policies have the support and approval of all levels of management.

Retention Period of Medical Records

Some billing records may have evidentiary value in a legal proceeding for which the practice may have liability. These records should be retained indefinitely, regardless of the normal retention policy for that document type.  

Records that should be retained for at least 10 years include logs of patient and insurance payments. Any document that provides the details of specific payments such as checks and ledgers should also be retained for this period of time. Additional records in this retention category include insurance vouchers from Medicaid and Medicare, in addition to any legal entity with which the practice has a contract. Any original documents relating to a dispute that a patient has with a bill should also be retained for at least 10 years.

Other records such as bills, claims and demographic records should have a retention period of at least seven years. Monthly balance reports and other reports of patient activity can also be destroyed after seven years in most cases. Additional documents with a seven-year retention period include records that facilitate claim payments, assuming they aren’t already part of the patient’s medical record. This category typically includes documents obtained from external sources by patients and insurers.

Secured Storage Policy

Records with different retention periods should never be stored together. They should also be stored according to their time period, meaning that weekly reports should be stored separately from monthly reports. Document containers should be labeled on the outside with relevant information such as the types of documents they contain, the reporting period they cover and the date they may be destroyed. Reports should be filed by date, while records on individual patients should be filed by patient name.

Only personnel who have been authorized by the director of the facility should be able to view billing records. The containers for archived records that aren’t referenced daily should be locked and stored as securely as possible.

Shredding the Old Medical Records

Each department should conduct a review every six months to determine which documents under its control no longer need to be retained. These documents should then be destroyed in accordance with a HIPAA complaint policy approved by the appropriate administrator.

Summary

M-Scribe Technologies, LLC is a national leader in medical billing services. We provide a range of service for your back office such as auditing, billing and coding services. Contact us today at 770-666-0470 or patrick.dougherty@m-scribe.com to find out how we can help your practice.

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