Current regulatory atmosphere designed to ensure that appropriate payment is made for appropriate services. Individual physicians, private practices, group practices and larger clinical practices cannot leave anything to chance. Recovery Audit Contractors (RACs) are focused on determining if available documentation supports the charges billed to Medicare and Medicaid.
Speech recognition or voice recognition (SR/VR) software that is being used frequent to by providers and support staff for such documentation is a valuable tool, but it cannot provide the assurance that every word in the record is correct the way that a medical document specialist or medical transcriptionist (MT) can do.
After working with almost all the speech recognition software in the medical transcription industry from last 15 years, we feel it’s both a benefit and a hurdle. While it is convenient for a health care provider to be able to dictate directly into the electronic medical record, the software cannot offer the same oversight and correction that an experienced documentation specialist or medical transcriptionist can do. Direct dictation via speech recognition servers cut down on overhead needed to employ a transcriptionist, but the end result may be not perfect record of provided services. Speech recognition software has not yet reached the state of technical perfection to be able to accurately translate accents or quirks of the spoken word. Health care providers often find that they need to review and edit their medical record entries more thoroughly than they did with a medical transcriptionist who was familiar with their documentation style and standards.
In spite of great progress in recent years there is still no digital substitute for acquired professional insight. Medical document specialist or medical transcriptionist ensures that medical documentation adheres to industry-wide standards. They communicate directly with providers through pointed queries when they suspect documentation or terminology does not reflect what may have happened during a patient encounter or procedure. A certified professional knows what to expect from a medical record. The record is more than a collection of data; it is a narrative that justifies the provision of services. If the contents of a medical record are not intelligible to a person proficient in the field, the medical record will not be acceptable for justifying services during a third-party audit.
Robotic surgery is performed under professional physician guidance. No qualified physician would let the machine perform the surgery on its own. Medical documentation is just as vital to the business of medicine. A machine cannot be trusted to provide an audit-proof medical record without professional oversight and intervention.
For a fixed low cost, health care providers can ensure that their medical records are documented with the same intent with which they were dictated. Billing efficiency is streamlined as documentation is clarified at the entry point, and the codes and charges extrapolated from documentation accurately reflect the contents of the electronic medical record (EHR). By being able to use commonly available devices such as the iPhone, iPad, iPod, or traditional dictation devices, entries can be made efficiently when time is available.
Physician and ancillary provider time is best spent treating patients, not in the review and editing of an EHR, nor in learning new software. By employing an affordable professional service to do the data entry, providers can see more patients in order to increase efficiency and profitability. Providers are not paid to check their documentation; they are paid to treat patients. This is why contracting with a reliable EHR service maximizes patient care while decreasing the chance of unsubstantiated billing findings in an audit. By establishing templates and commonly used abbreviations and terms that speech recognition software may be unfamiliar with, new generation documentation specialist promotes accurate documentation of provided services that a physician can recognize as his or her own. A RAC auditor will also recognize the records accuracy.