By: Jacqueline Bain
The transition from paper medical records to electronic medical records has brought with it many conveniences and some unintended consequences. One example of an unintended consequence is cloning in the medical record. Cloning is copying and pasting previously recorded information from a prior patient note into a new patient note.
Providing quality medical care is only one part of the job. Appropriately documenting that care in order to be paid for your efforts is another. And while medical professionals are trained at length to provide care, hardly any are aware of the potential pitfalls associated with improper documentation.
In late 2015, CMS advised that cloning “is a problem in health care institutions that is not broadly addressed.” CMS specified that cloning records may indicate fraud, waste and abuse in inquiries and audits and that each part of a “medical record must contain documentation showing the differences and the needs of the patient for each visit or encounter.”
So, what’s the problem? Copying and pasting prior information does not indicate why a patient has presented for a subsequent follow up. A cloned record doesn’t indicate whether the doctor had a meaningful interaction with a patient, and it doesn’t reflect the often in-depth discussions that a medical professional has with his/her patient which would lead to a diagnosis and treatment.
Moreover, cloning calls into question the legitimacy of the record itself. “Medicare contractors have noted an increased frequency of medical records with identical documentation across services.” How can a physician substantiate the time spent with a patient if each note is identical to the last? MACs have started to deny payments on the grounds that cloning is a “misrepresentation of the medical necessity required for services rendered.” First Coast, which is the Medicare Administrative Contractor in the State of Florida, has stated that cloning “will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”
Imagine if you are working for an insurance company and repeatedly see multiple lengthy visits with the same record attached, or maybe one or two extra sentences at the end. Wouldn’t you question whether the physician had a meaningful encounter with the patient? Would you be able to tell the substance of the physician’s interaction with the patient from the cloned note?
Even Federal courts have taken aim at cloning medical records. Last year, the 11th Circuit Court of Appeals (which has jurisdiction over the State of Florida) affirmed a conviction for healthcare fraud, noting that “therapy notes were copied and pasted from one session to another so that patients’ files contained multiple versions of the same notes.” The court inferred that the duplicate notes were created in an effort to cover for services not actually rendered.
Failing to take the time (between patients, at the end of the day, after business hours) to accurately document each patient encounter can lead to potentially devastating consequences. From not getting paid for services rendered, to being required to pay money back even after it is paid, to an implication that your services were rendered in a fraudulent fashion, please come away from this post knowing that cloning medical records is not a good idea. Make an effort to ensure that your records document each unique patient encounter in order to avoid this scrutiny.