Proving the medical necessity of each provided service has become the new challenge for securing fair reimbursement. The evolution of documentation requirements have now become much more clinically-nuanced, requiring detailed insight into how the patient-care event evolves throughout a patient’s stay.
With a board-certified physician at our helm, Brault not only understands a physician’s language and thought style, but also the factors that motivate them and the best ways to focus their efforts toward better documentation. Brault’s industry-leading documentation training includes:
Fundamental Areas of Training
New-client orientation typically involves a review of the practice’s electronic medical record (EMR), to determine how they are using it. This process not only helps orient our collaborative teams, but also uncovers areas for improvement and training. Experience with more than 20 different EMR’s allows us to identify, ahead of time, common pitfalls of EMR usage.
Chart Detail Requirements
The ongoing shift from volume to value in determining payments places much more emphasis on effectively communicating the value of care. Historical challenges like history and exam are now being superseded by demands for records to clearly identify why providers did what they did, not just document what they’ve done. This is why Brault takes a clinical approach to documentation improvement. Not by telling you to use “a phrase that pays,” but by helping you find clinically useful statements that are reimbursement compliant.
Onsite Group Training Sessions
New client orientation typically involves an onsite documentation training along with an EMR review to determine how your practice currently uses its EMR, and where relevant documentation should be housed within the system. This group training at start-up, followed by annual updates, allows everyone to receive the same information and share ideas and concerns during open discussion.
1-to-1 Online Training
Providers who want to improve their charting skills may request 1-to-1 online training with a Brault Practice Improvement Specialist – including a chart-discussion format that is tailored to each provider’s specific practice style.
Scheduling a training session is as easy as clicking on a web link. Providers simply select a topic of interest and schedule an open time slot, and our Specialists collect relevant examples from their work to jointly review over a shared computer screen.
Clients can also request acuity reviews to identify declining levels of care, or reporting ratios that fail to meet internal benchmarks. And, if indicated, Brault can proactively suggest training interventions and onsite meetings to help correct the issue(s).
On-Demand Documentation Materials
Brault offers a library of on-demand tip sheets and webinars related to common health challenges. These materials are instantly accessible and easily shareable via email. Documentation improvement materials are available in the areas of:
- Wound care
- Fracture care
- Critical care
- Observation care
- Differential diagnoses
- Diagnosis reporting
- MIPS measures
- History and physicals
- And many more
Documentation & MIPS Reporting
For quality assurance, Brault provides monthly reports detailing, by physician, the volume and types of documentation deficiencies that are causing lost income. There are more than 25 discrete causes of revenue loss, each of which can be tracked by provider (with related RVU and charge losses). MIPS tracking reports can also show monthly and year-to-date performance scores related to the quality measures that apply to your practice.
And, to ensure that documentation improvements remain top-of-mind, Brault can create action plans from these reports – with detailed training interventions to help increase MIPS scoring and produce additional income.
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