Hello and welcome to this presentation on health care compliance for the front office. My name is Linda Fitzum, CMA, AAMA. I just detailed the learning objectives for this course. There are five objectives, as you can see, and I'll give you a little hint that two through four tie into what the first objective is. So I will read them to you briefly. First objective is to define health care compliance. Two through four, the second, third, and fourth objectives are just ways that the front office staff can improve inpatient safety, protect patient privacy, and ensure proper billing and collection techniques. And the fifth objective is some tips and tricks on some documentation basics for the front office staff. This slide is more or less a disclaimer. As always with any organization, you need to follow the policies and procedures of that organization. This presentation cannot take into account the policies and procedures for every office. It also cannot account for any specific state laws. So just keep that in mind. Up to our first learning objective, what is health care compliance? I'm not going to read this entire slide to you, but this bolded part is the actual definition. It is the process of meeting or exceeding the legal, ethical, and professional standards that apply to a health care entity. If you read all of these bullet points, common themes that will come is it involves the law. The first and second slide say that explicitly with the words legal and laws. The third bullet point mentions some possible crimes, and it also mentions the word liability that has to do with law. The last bullet point says that health care compliance is active, ongoing, and varied. And it also says that there are regulations and requirements. So health care compliance is very important. There might be legal ramifications to not following this. So just take a moment and read through this slide, and then we'll move on. I spent a lot of time on this slide, but these are just some references for the previous slide. Also, if you want some more information, feel free to click on these links. I'm going to go over each of these topics in more detail, but these are the three main areas of health care compliance, safety, privacy, and billing. And if you think about it, these are important topics not just in health care, but in day-to-day life too, your safety, your privacy, and your money. These are all very important, and we will go over them in more detail. I say this a lot. The front office is first. The front office are the first people that patients will encounter, either by walking into the office or over the phone. So you will hear me say that a lot. The front office staff, you all are very important. You are the face and the voice of the office. And that would be either in person when they walk in, over the phone, or if they're having trouble with a virtual appointment. So get used to me saying a couple of things over and over. The front office is the first. And check with your manager. Who is responsible for patient safety, patient privacy, and patient billing? The short answer is everyone in the office. Now people's scope of practice is going to vary. People's job responsibilities will vary. But everyone in that office should work as a cohesive team to ensure patient safety, patient privacy, and accurate billing. Compliance should be a priority. To just take a moment to think about you working in your position and how and what you do for healthcare compliance, how you fit in as a team member within your office environment. Just take a moment to think about that. What is it that you do to ensure patient safety, privacy, and proper billing? Everyone plays a part. The front office staff is the face of the office. They are the first ones that patients see and talk to. The front office staff will see patients before and after an office visit. A lot of times patients might forget something and they might mention it to the front office staff. And generally, clinical staff is going to defer to the front office staff in matters relating to insurance and collecting. People recognize other people's areas of expertise. So this is what the front office staff brings to the office. And the front office staff can be very pivotal at ensuring patient safety. This may not seem apparent. The next few slides will go over it in detail. But once again, I'm going to hammer that point home. The front office staff are the first ones that see the patient. So they might be the first ones that see potential safety issues and can work as a team to help alleviate those safety issues. And we'll go over that in more detail over the next slides. But I just want to hammer it home that a lot of times the front office staff are the first ones that might notice these things. So just keep that in mind over the next few slides. I won't read each point. But as you can see, safety is protecting from or unlikely to cause injury or damage. There are two main types of safety, physical and emotional or psychological. So you might be thinking, what can I do to help promote safety? There's a lot. We're going to go over it. But just take a moment to read through this. And then we'll go on from there. I just want to just point out there is a very important, the most important part of safety. It doesn't matter if you work in a medical office, if you work as a contractor or climbing up telephone poles or work as a first responder. There is one important thing that you must always keep in mind. The most important aspect of safety is to put yourself first when it comes to safety. Maintain your own safety at all times. You can read through these slides, but just keep in mind if you've ever traveled on an airplane, you will be told to put on your own oxygen mask before assisting others. Keep that in mind whenever we discuss safety in the workplace or anywhere else. Some things that are very useful that the front office staff can do is ask patients about accommodations that might be needed. Wheelchairs, Hoyer lifts, other assistive devices. Maybe they need an oxygen tank to be on hand because what they have might run out. All of these things can be ascertained before the appointment. And then everyone can make sure that these are on hand for the patients. This ensures their physical safety. It helps with their psychological safety. And it really shows good customer service. These two examples are other ways that the front office staff can help with patient safety. There have been times where patients have come into the office and the front office staff has recognized that they just don't look good. And they've alerted clinical staff and it has been a merchant situation. In my own time, I have seen patients come to the front desk complaining of chest pain. I have seen that more times than I would like to admit. I've had patients come to the office with dangerously high blood pressure. And for some reason, rather than going to their primary, they came to a urology office. Luckily, we were able to convince that patient to go to the emergency room. But these are all ways that the front office staff can see things that are going on and prevent emergencies and help with patient safety. And I'm going to say this basically the same thing over a few slides. Being prepared for medical emergencies or for other situations and knowing how to react is very important. Everybody should have a clearly defined role and every office should have some sort of policy and procedure and more important training where this is hammered into everyone. If a patient comes in complaining of chest pain, what happens? If there is an active shooter situation, what happens? It's very sad that we have to prepare for these things, but these are things that we need to prepare for. So taking steps to be prepared so that if a situation happens, everyone can react calmly is very important. How to defuse certain situations is another way that front office staff can ensure the safety of people in the office. Patients might be agitated because of a billing situation. They may be agitated because of medications. I have seen this more than once where patients will want to start altercations with each other in the waiting room. So just knowing how to handle those situations would be useful. That would be something to discuss with your office manager and get some training on that. The way that front office staff can ensure patient safety is over the phone. Sometimes patients will call with emergent situation, and usually those calls will need to immediately be transferred to clinical staff. But again, just the same as the front office staff being able to look at a patient and telling that something isn't quite right, a lot of times we can also hear things that might be amiss over the phone. So just getting to know those patients and just listening to them. If they are talking about certain things, certain things should be immediately sent over to a clinical staff member. Any chest pain, shortness of breath. Maybe they are having extreme pain. Maybe they are exhibiting throat swelling, some kind of rash that might be an allergic reaction. Things like that, it would be to alert the clinical staff for. It's outside the scope of practice to diagnose things, but it is good to bring up concerns to the clinical staff or providers so that issues can be taken care of. Let's sum up patient safety by saying that the front office staff are the eyes and ears of the office. They are in a unique position to communicate patient concerns to the clinical staff and the providers. So therefore, open communication between the front office, the clinical staff, and the providers should be encouraged. Now let's move on to discuss patient privacy. Usually, whenever we discuss privacy in the health care setting, the first thing that comes to mind is HIPAA. So that is what we are going to discuss in the next few slides. This slide and the next slide detail the civil penalties that an individual or company may face with HIPAA violations. So just take a little bit of time to read this. The next slide has the same information. It's just in an easier to read format. This is the same information on the last slide. Hopefully, it is easier to read. The main takeaway from this is that even if an individual or entity was unaware of a HIPAA violation, they can still be found liable. Any of the fines and criminal charges will not just be levied against an organization. They can also apply to any individuals who are found to be involved with these violations. So just read through this slide and then go back to the previous slides with those amounts and just keep that in mind on why it is so important to maintain patient privacy and not to violate any of these rules. Information. It is not worth it to sell or use any protected health information for personal gain because you can be fined up to $250,000 and receive a prison sentence for up to 10 years. It's not worth it. Don't do it. I think that the title of this slide says it all. A prison sentence of up to 10 years and a $250,000 fine is not worth it. It just simply is not worth it. So avoid even the appearance of misusing protected health information for personal gain or to sell it. Don't do it. Don't even give anybody a reason to suspect you of doing it. As the slide says, it's not worth it. The next few slides are going to go over some scenarios. There are three of them. Take a moment to read through them and we'll go over them in more detail on the next few slides, but just look through them for now and think about what you would do in these scenarios. They may seem a little outlandish, but things like this have happened in real life. Okay, so you're at work and for some reason you find out that one of your friends has a terminal diagnosis. You're a good friend. You know that maybe this person has a family and you want to help them by starting a GoFriendMe page. So below I have some questions. First of all, did your friend ask you for help? Did your friend even tell you about the diagnosis? This might be a situation where this person is still processing this information and they have not told anybody. So they probably would not want to see a GoFriendMe page pop up. Keep in mind that HIPAA does not differentiate between trying to cause harm or trying to do good. You know that the road to a certain place is paved with good intentions. The road to HIPAA violations is also paved with good intentions. And something else to keep in mind is that if your friend did ask for help and did want you to start a GoFriendMe page, considering that you work for the place that this person receives treatment from, do you think it would be a good idea to start that page? Now, we live in a community. We want to help our friends and neighbors. Starting a GoFriendMe might be a good thing for this person. But maybe somebody else needs to start that page. Just keep in mind that HIPAA does not care what your intentions are. People process news differently. They may want to keep this to themselves. They may not want a GoFriendMe. This person might have adequate savings for this, and you don't know. If you find out about this at work, as opposed to this person coming and telling you, you really don't know what they need. Oh boy. Don't do it. Don't use the workplace as a place to get ammunition against those people that annoy you. Working in healthcare, you may inadvertently find things out about people that, quite frankly, you don't want to know. So you may find out that somebody has a mental health diagnosis. You should never mention that outside of work. And you should never say something like, being crazy doesn't mean you have to act crazy. This is clearly a privacy violation. It is clearly an unprofessional way to conduct yourself. And even if you are outside of work, you have to maintain a certain level of professional decorum, especially when it comes to patient information. Keep in mind that even when you're not at work, you're still considered a part of the office. So use some discretion when it comes to these types of matters. These scenarios are just going from bad to worse. Scenario one is good intention, but a privacy violation. Scenario two is mean-spirited and a privacy violation. Scenario three is a criminal offense or multiple criminal offenses as well as privacy violations. It is not worth it. Read through the side and look at the fines and possible prison sentence that you might get. And also keep in mind this last sentence. This does not account for any civil lawsuits that might be filed. So it is not worth it. Is this something that a front office worker might be faced with? This is a possibility. So just keep that in mind. This information is valued on the black market, but it is not worth it for you. It is not worth going to jail. It is not worth these fines. So now that we've gone through everything that can happen if a person violates HIPAA, let's finally get into defining what HIPAA is. HIPAA stands for the Health Insurance Portability and Accountability Act. As you can read, it is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge. Basically, this gives patients the right to know who is accessing their health information and for what reason. And it also gives patients the opportunity to access their own medical record. One of the things that the HIPAA laws did was define what is protected health information. The most basic definition of that is it is any information that can identify a patient that is being used for treatment or billing purposes. So just think about ways that this information might be displayed, even if it doesn't seem like it is being displayed. Just keep that in mind. In the office, how easy is it for people who do not have a need to know to see someone's information? So overall, there are 18 elements identified by HIPAA that are considered protected health information. One thing to keep in mind is that these only apply if the information is used for billing or treatment. So if one of these 18 identifiers has nothing to do with billing or treatment, then it is not considered one of these elements. This slide goes over some of the 18 identifiers. Some of them seem very obvious that they would allow you to easily identify a patient. Some of these, such as geographical location, do not seem specific enough. However, geographical location was actually a way that one nurse got fired and charged with HIPAA violation. She had posted on social media about a pediatric patient that was treated at a certain hospital for measles, and it was very easy to find out who this patient was. So that was a privacy violation, and she was fired, and I believe she lost her license. So just keep that in mind that some of these categories are very broad, but if they can be used to identify a patient's treatment or billing information, it is one of the protected identifiers by HIPAA. For more of the identifiers, some of them might seem less obvious. So let's go through each one, starting with vehicle ID. If a patient is being treated under auto insurance, the vehicle ID might be a way to link a specific patient to that claim or to that treatment. Device ID or serial number, think of continuous glucose monitors, pacemakers, prosthetic joints. All of those things would have a device ID and a serial number that are usually specific to a particular patient. A web URL or IP address, IP address can be linked to a specific location, an IP address that could be where a patient is receiving treatment. So maybe the IP address is coming from a specific hospital, and that IP address can be linked to that patient and identify that the patient is at a specific location getting treatment. A web URL, this could relate to patient portals, this could relate to any of the various apps that patients use to augment their health. All of this would contain patient information. Biometric information is pretty obvious. Fingerprints are very unique to the patient. So things like that, fingerprints, retinal scans, that can all be tied to a specific person. A full face photo is obvious. You may not have the patient's name, but if you have a full face photo, you can tell who it is. And any other unique identifier, maybe specific scarring, tattoos that are very unique to a specific patient, that could be used to identify a patient. All of the identifiers here are dates relating to the identity of the patient, date of birth and date of death, but you also have date of admission, date of discharge, and the exact age of a patient older than 89. Now, the date of admission or date of discharge may not give you the exact information on a particular patient, but there could be some localities that are more remote. So maybe there was a day that only one patient was admitted or discharged on a specific day. So those are other things to keep in mind too, these dates. People may not think of barcodes or QR codes as patient identifiers, but a lot of times laboratories will use labels with barcodes that have the patient information encoded in them. And I have personally seen on some social media sites like Facebook, where there would be lab forums and people would post pictures of specimens and other people would say you shouldn't post that because there's barcode showing and that could be easily read and that patient information can be on the internet. So that's just something to think of. If you're in the situation where specimens are kept up front for a courier to pick up, just make sure that no patient information, including barcodes, is able to be seen by anybody in the lobby. Just a thought. The next few slides are going to go over some ways that the front office staff can protect patient privacy, but this is something that everybody should do. Front office, clinical staff, providers, protecting patient privacy should be something that everyone wants to do to the utmost of their abilities. But the next few slides will just go over some helpful tips and tricks. Generally speaking, the front office staff does not have the ability to take the patient somewhere private to discuss things. If you work the front office, you are generally answering phones and you have patients coming up to the window to either check in or check out. So these first two bullets are more specific to front office staff. Usually the clinical staff can take the patient into an exam room or somewhere private to discuss things, but if you are in the front office, you generally do not have that luxury unless you are a surgery scheduler with your own office or you work in billing and are setting up a payment plan with a patient. So if you are on the phone with someone and you ask them for identifiers, don't repeat it back if another patient comes up to the desk. And if you're on the phone and someone comes up to the desk, maybe try to put that person on hold so that they don't hear each other's information. The third and fourth ones are general information that everyone should follow. Don't discuss patients in non-work areas and try to make sure that any forms with patient identifiers are either disposed of properly or filed properly. They should not be left out. And this is something that I've seen both front office and clinical staff be guilty of. Always about protecting privacy. One thing that we need to be careful of nowadays is social media. A lot of people in health care have TikToks and some of them are very educational or humorous. But the best ones, the patients do not show other patients or discuss other patients. They might talk about generalities. It might be in a question and answer type thing or it might be a little skit that describes a very general situation. But be careful about what you post on social media. Do not vent about patients. Be very careful about what you vent about, about the workplace. Even if you feel like you have not identified a certain patient, you may have. Or someone completely different might feel that you were discussing their issue. So this is something that could create a possibility that you are violating patient privacy and it's also very unprofessional. Another thing is to not act like a spokesperson for your workplace unless you are employed as such. I know that on a previous slide I said that you have to act with professional decorum and in a way you are representing your workplace even when you are not at work. But trust me, leave being a spokesperson to the people who are employed for that. It is a lot of stress. If you are acting as a spokesperson, you have to say everything exactly right. So unless you are employed in that position, do not act as a spokesperson for your workplace. And if you want more information, there's a lot of information about HIPAA and social media. Let's talk about public health versus personal health information. HIPAA does permit certain information to be disclosed without the patient giving consent. If the purpose is to protect public health, control disease, and control and monitor injury and disability. I attended a lecture a few years ago from a gentleman who worked for a local department of health and he basically said that if he calls the office, we need to disclose because public health trumps protected health information. There is a link with more information and basically just follow your office protocols for this. I'll go into a little more detail in the next slide. The reason why I included these two slides is that we had a front office person who was not sure what to do with calls from the local department of health. So we just told her that those calls needed to be handled by one of the clinical staff. And usually the department of health will already have the patient's name and the diagnosis. They are just looking for some further information regarding treatment or length of the illness. So just check with your manager about how to handle these calls. Certain specialties will get more of these calls than others, but just check with your manager. And usually if these calls happen, they're going to want to talk to a member of the clinical staff, but these are usually not HIPAA violations. The next few slides are going to go over billing. Billing is one of the areas of healthcare compliance. Just remember that most of the billing information is protected health information, so billing and privacy are very intertwined. Diagnosis and procedure codes are not considered protected health information. However, you want to avoid referring to a certain patient by a diagnosis code or a procedure code, even if you use the code. Other people might know exactly what that code means. So if you say, oh yeah, Mr. Jones is the B20 patient, then you've not only potentially identified a specific patient, but you have identified what that patient is being treated for. So just keep that in mind. We're just going to touch a little bit about billing and healthcare compliance overall. So the next couple of slides will go into that a little bit further. Even if your office has a separate billing department or they outsource the billing, the front office staff is going to collect billing information, which again is protected information. They're going to verify the insurance, get authorizations, and collect money. So it's very important for the front office staff to make sure that they are acting in a way that is compliant. In some offices, the office staff will submit billing to the insurance companies. Usually, the provider will code for this, but just be wary of any one-size-fits-all codes. Some electronic health records will provide a code based on documentation because billing has to be based on the documentation. If you are asked to provide a code based on the documentation, you will have to do the billing, make sure that you follow your office policy and any applicable laws. You can read this slide. It has very serious consequences. You may not be directly involved with billing. You may be directly involved with billing, but that information that you collect that I mentioned a few slides ago, verifying the insurance, all of that is something that needs to be done accurately. You may need to provide patients with estimates for any upcoming procedure. That needs to be done, and the reason why is because even if it was an error, it can still have these consequences. It does not need to be done with malicious intent. It could be an error. So just keep that in mind and be careful when you are collecting that billing and insurance information. Last but not least, keep patient information private. Make sure that there is nothing containing this information lying around, anything that has to do with what a patient is being treated or billed for. Just read through it. We've kind of gone over all of these already, but do not walk away from your computer. It should be locked and password protected. Payment information should be secured. A lot of times patients might have a card on file for payment, so all of that information needs to be secured. We are going to go over documentation and how that ties into compliance. Front office staff is usually not taken into consideration when we discuss documentation, but there are things that the front office staff does that is very important and does involve documentation. One of the common things that easily springs to mind is phone calls. Usually the front office staff answers all of the phone calls, so they might need to document a phone call. It can range from an administration question that's as simple as rescheduling or canceling an appointment. It could be a billing question. It could be a clinical question that they take the information down and send it to the clinical staff. It also involves administration intake. This information that is collected that regards patient information, insurance information, that information needs to be collected. It needs to be uploaded to the medical record in an appropriate manner. Documents may need to be scanned into the chart. Data entry might need to be involved, but all of this is documentation. So let's do some documentation basics. Everybody should have a basic understanding on how to document in the medical record, and one of the things that you just want to make sure of is that the right information on the right patient is getting into the right chart. When I went to school for medical assisting, one of the things that I was taught, which I am going to share with all of you, is to imagine that your documentation is magnified and projected on a screen in a court of law. That has really helped me take a step back and make sure that I am documenting correctly. This isn't meant to scare anybody, but it is just something to consider because you never know what might wind up in a court of law. So I try to take it that everything I document might wind up in a court of law. And in general, the front office staff doesn't document on clinical details as much as the clinical staff or provider, but knowing the basics will help you out and make it less likely that you violate any rules. But just always keep in mind that different offices have different protocols about who documents what in a patient's chart, so just always check with your office manager and follow your office protocols. Always use proper spelling and grammar in your documentation. If the electronic health record has spelling and grammar check, take advantage of it. Avoid the use of abbreviations and acronyms. If these cannot be avoided, then make sure you are using them correctly. And as always, know and follow your office protocol for taking messages. Sometimes medical acronyms have to be used. MRSA, or methicillin-resistant staphylococcus aureus, is a lot to say and it's a lot to write out. Therefore, MRSA is just easier to say and it's easier to write. However, I have seen it spelled M-E-R-S-A, M-U-R-S-A. I don't know what those mean. I have also seen, well, SOB stands for shortness of breath. I have seen where somebody has asked a patient if they are SOB, so just be careful of things like that. One thing that is very confusing is abbreviations for other health care entities. So, these are all abbreviations that I've seen and they can be very confusing. Another reason to avoid medical acronyms, I've seen this on the clinical side and I know that this is for a front office, but I have seen this on the clinical side. One of a co-worker was calling a patient back with lab results and the doctor said that the K was a little elevated. K is the chemical abbreviation for potassium, but this person was new and thought it meant vitamin K. So, that's another reason why medical acronyms should be avoided or just make sure that they are used properly. These are just some of my own thoughts about the use of abbreviations and problems that we have encountered, and I have been guilty of misusing abbreviations. I'm not just wagging my finger. This is a lesson that I had to learn myself. There might be a situation where a hospital has a standardized list of facilities that are abbreviated and everyone in that location knows what that means. However, when that patient is discharged and outpatient offices are trying to track this patient down, they are having to call the hospital and ask what this abbreviation means, and that just takes time from the nurses on the floor. It takes time from the outpatient staff. So, this is just something that I've observed on why it might be good to avoid the use of abbreviations. Here's another little trick. If your electronic health record has a portal, it's a great idea to encourage patients to utilize it. A lot of people might assume that older patients are reluctant to use it, that older patients don't like technology, but a lot of times older patients or patients with hearing issues prefer communicating this way because they can write and read text. And another good thing about this is that it allows the patient to document exactly what they want, and portal messages generally go directly to the person or the department that they need to go to. So, that is useful as well. So, just something to keep in mind is that this can put some of the onus on documentation on the patients, and we don't want the patients to have to do our job, but this will allow patients to communicate in their own words. Text macros are probably the best thing about an electronic health record. You can also use these in word processing programs, but basically a text macro is a command that will produce text. So, if you're ever in a situation where you have to write the same thing over and over, especially if it is something very long, a text macro will allow you to basically type period and then a couple of letters and all of that text will appear. You can also use this for fillable text. So, if you have a long string or a short amount of text that you have to fill in the blanks at certain parts, you can also do that with a macro. I use macros in my documentation. I find them extremely useful. If your electronic health record has a text macro, make sure that you're aware of the proper policies and procedures with using them and use them correctly, but they save a lot of time and they are really useful in documentation. Here are some basics on taking a phone message. I cover the phones a lot. I started out in internal medicine. The phones were very, very high volume. So, here are the basics. Make sure that you properly identify the patient with at least two identifiers. Name and date of birth are the most common. Try to find out the reason for the call. Do they need a refill? Do they need lab orders? Do they have a question for the staff or the provider? Are they having any kind of emergency? Remember way back in the beginning when we were discussing patient safety, are they complaining of chest pain or a possible allergic reaction? Is there something where you need to get the clinical staff involved immediately? And just as a general courtesy, it's a good idea to always give the patient a timeline of when the call will be returned. You could say, Mrs. Smith, the clinic is going on right now. The last patient is scheduled at 1130. You should hear from either Susie or Sally no later than 1230 p.m. today. Is there anything else I can help you with? It is not easy answering the phones. There are always difficulties in taking a phone message. Patients may be reluctant to give information to the front office staff, especially if the information is sensitive. They may also feel like they would have to go to the front office to get the information. Sometimes a patient may not be able to articulate exactly what is wrong. And sometimes patients just don't feel good and they're not going to be very pleasant. Another issue is that the patient may not be able to communicate with the front office staff in a way that is pleasant. Another issue that is encountered is that a patient might be hard to understand or hear over the phone. So all of those things are obstacles to assisting patients, but they are obstacles that we need to overcome. There are ways to try to overcome the difficulties. If a patient does not want to give the reason for the call, sometimes it helps to gently advise them that the staff or the provider may need to do some research before calling them back. And generally the response will be quicker. In general, don't force this issue. It's best to try to get a reason for the call, but we also don't want to needlessly agitate patients. If a patient is having trouble articulating what is wrong or they are hard to understand, try to ask some probing questions. Work with your manager and clinical staff to determine basic questions to ask over the phone. The patient may need an assistive device for the phone or the patient may be more comfortable using the portal. Different specialties have different probing questions that might be good to ask, so I would always say to check with your manager and the clinical staff on when it's appropriate to ask these questions and what kind of questions are good to ask. If the patients are not pleasant, try to use empathy. It's not personal, but don't allow them to be abusive. Calls may go to voicemail. That is a fact of life if the office is busy. Calls that go to voicemail should be documented the same as calls that are answered by a live operator. Some patients leave very detailed messages and you will come to really appreciate those patients. They identify themselves, they identify a callback number, they state the reason for their calls. Some patients may not identify themselves. Some patients may identify themselves but not give the reason for the call. Some patients may not provide a callback number. You may get messages on a business voicemail that sound like this. Hey, call me back. Bye. In cases like that, you may need to find a way to find out what number that voicemail originated from and call the patient back and then document the reason for their call. But voicemails need to be treated the same as incoming calls that were answered by a live operator. Whether or not to directly quote a patient. I will tell you a little story about why I have included this slide here. Sometimes it is very useful to directly quote a patient. Descriptions of pain. In this slide I say a patient may describe burning constant pain as it feels like my leg is being bit by fire ants all the time. That is very descriptive. Anybody who has been bitten by a fire ant would know what that feeling feels like and if that information was relayed to the provider they would probably have a sense of what is going on. Another useful way to directly quote a patient would be if there is specific information that the patient wants the provider to know. So in this case the patient is saying basically that they agree with the provider's treatment plan but they are unable to comply with it. Directly quoting the patient serves two purposes. It shows that the patient understands that this treatment of care is beneficial and it is also stating that the patient is unable to comply with it. The provider may be able to change the treatment plan to something the patient is able to work with and also this protects the provider by clearly documenting that the patient understands that this plan of care is a good one. You can read through this slide and see the reasons when not to quote a patient directly. I have seen the first one in practice where someone transcribed a very explicit and colorful email, I'm sorry, voicemail left by a patient. That is, do not do that. You can just say patient used explicit language to express displeasure. If a patient is talking about a specific staff member or providers, do not directly quote that. And finally, if a patient is using poor grammar or spelling, it's not our job to demean that patient by directly quoting them. We can paraphrase it and document it in a way that has proper grammar and spelling. If we know what the patient means, we do not have to worry about subject verb agreement and things like that. So there are some other links that you could click for some more information. This is the last slide in our presentation. So thank you for joining me on this. Let's just bring it all together. Your office policies and procedures for healthcare compliance should be clear and readily available. Hopefully they're getting updated at least once a year. It's everyone's job in the office to protect patient privacy, safety, and billing information. I really hope that you work in an office with seamless communication between the front office and the clinical staff. Those offices are a joy to work with and they have better customer service. That has been my experience. And just keep in mind that it is harder for the front office staff to protect patient information because you typically work in an area that is more open. So hopefully there are ways that you can take steps to protect that information. And finally, knowing some of the basics of documentation will help you, your team, and the patients. So thank you very much for attending this presentation.

health care compliance

front office

Linda Fitzum

patient safety

patient privacy

accurate billing

HIPAA

protected health information

medical emergencies

office protocols