On Feb 26, 2018, Delmarva Foundation, Health Integrity, Quality Health Foundation, and Quality Health Strategies came together under a new name: Qlarant.  The following content was created prior to this change and may contain our old name(s).  Learn More

Understanding the Importance of Your Clinical Summary

If you have been to see a doctor lately you’ve most likely been handed a sheet of paper (or several) at the end of your appointment. Do you take the time to review this document or do you just toss it aside? This document is called your clinical summary. In addition to providing the details of your appointment, these documents are a part of requirements set by the Centers for Medicare & Medicaid Services (CMS) known as “meaningful use”.

The American Recovery and Reinvestment Act of 2009 established incentive payments to eligible professionals, hospitals, critical access hospitals, and Medicare Advantage Organizations “to promote the adoption and meaningful use of interoperable health information technology (HIT) and qualified electronic health records (EHRs).” Tied to this Act is the EHR Incentive Program that provides incentive payments for certain healthcare providers to use EHR technology in ways that can positively impact patient care. To meet the objective of this program, and receive the incentive payments, providers can attest that they are meaningfully using their certified EHR systems by providing patients with an informative summary of their visit. Conversely, providers who did not meet the meaningful use requirements by 2015 are subject to a reduction in their Medicare reimbursements. https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html

Now that you know why you are getting this document, what should you do with it? All of the information is pulled from your medical record with that provider, so you should review it for accuracy. Does it list your allergies correctly? How about your current medications? Most summaries also include the procedure and diagnosis codes used to bill for the services you received. It is important to review all of this information to prevent inaccuracies within your permanent medical record as well as to understand what will be submitted to your insurance company. I recommend saving this document to compare with the explanation of benefits (EOB) mailed to you from your insurer. To protect your privacy, most EOBs no longer display the actual procedure codes that are being processed – only a vague description such as medical care or lab services. By comparing the EOB to the clinical summary you should be able to justify what was billed on your behalf and potentially identify erroneous charges.

Most EHR systems are populated by checking boxes on a computer screen. Sometimes the wrong box is checked completely by accident; however, there are unscrupulous providers who submit incorrect claims for the sole purpose of increasing their revenue. That behavior constitutes fraud and can cost Medicaid, Medicare, and private insurance companies billions of dollars every year. Be an informed patient and take a look at that clinical summary.

about the author

A portrait of Cindy Jones

Cindy Jones is a coding instructor for Qlarant, as well as a certified medical auditor assisting the medical review staff with integrity audits. See all posts from Cindy Jones.

Comments

    Sharron Wilkison says:

    If you are sent to a specialist. and only see the nurse practitioner I pay the price to see the specialist. If I see my primary cares nurse practitioner it is paid the same as the primary care cost. This is what I would call fraud on the specialty field. Am I wrong and why?

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