An essential part of medical-legal litigation, the medical record retrieval process involves gathering comprehensive medical documentation relevant to a case. Medical records have a major role to play when it comes to building a solid case and going on to win it, whether it is a medical malpractice, personal injury, product liability or other medical-related case. The process of retrieving records is time-consuming and even frustrating. Once they are collected, they must be organized for effective analysis and review.
Given the importance of medical records, attorneys must make sure to follow some best practices that will speed up the retrieval process, and save valuable time, manpower and other resources.
- Obtain permission or authorization from the patient: This is the most important first step in medical record retrieval. Plaintiff attorneys can get this authorization during the initial meeting with the plaintiff. To release the patient’s medical records, most providers will want an HIPAA authorization and so ensure that you get a signed form from the patient. Power of Attorney, Last Will, and Letters Testamentary are among the other authorizations required if the case involves a deceased or incapacitated individual.
Defense attorneys can obtain permission via a subpoena or directly through opposing counsel. It is best to get a limited Power of Attorney from the client that authorizes your law firm to sign on behalf of the client for medical record requests and information. This will help save the time and effort involved in going back to the client each time, especially with providers who may have their own rules, and special authorizations.
Sometimes, an authorization form may be rejected if some information is missing or inaccurate. In such cases, submit a replacement authorization instead of making changes to the original authorization.
- Request the medical records you need: First, you need to evaluate whether the case has merit. All the records may not be needed at this stage and so get only those medical records that are necessary to determine the case’s merit.
- To determine which records to request first, talk to the client to understand important elements of the case. Identify all the providers and the medical records necessary to evaluate the case.
- Requesting specific documents (including billing, medical, pharmacy, urgent care, physical therapy and so on) is important to ensure a complete medical chart.
- Request nurse notes to gain information regarding patient symptoms, complaints, and side effects.
- If the case is found to have merit, retrieve more records that may be required for trial.
- If you have any doubt regarding which records to collect, it is best to arrange to retrieve all the records.
- Ensure the records are complete: To make sure that you are working with a complete medical chart, review the records as they come for providers, medications, procedures and so on that were not previously identified. This task is best outsourced to medical record retrieval companies that can offer professional services. The retrieval process can be considered complete when you have all the documents related to all the details. Note down any missing or inconsistent details.
- Consider digitizing the records: Law firms may receive the medical records in paper and film forms as well. Storing the records as hard copies may not be the best practice because it involves considerable storage space costs, and costs for duplication services. Organizing the records and reviewing them can be very tedious and time-consuming. Moreover, having sufficient safety measures to protect these from theft, disaster and data breach can also prove expensive. On the other hand, electronic records are easier to organize, store, review, share and protect. Make it a point to scan and organize hard copy records as and when they arrive.
- Have a clear understanding of the providers involved: Providers may have their own authorization requirements, and ways of storing and releasing records. They may have individual fee schedules and turnaround time specifications. When a provider is part of a larger organization, you have to find out who the custodian of the medical records is. You may have to call the providers for initial contact and follow-up and it is immensely helpful if you get to know the providers very well. Subcontracted copying services working for providers may have their own schedules, which you need to know to get the records on time.
- Pay the required fees: The charges for medical records may include a flat fee and additional processing expenses. The provider may require this as a prepayment before releasing the records. Depending on the size of the medical records, this amount could be very high. Ensure that all payments are clearly documented and track the details of such payments to avoid double payment and overcharges.
Another important thing is to know the state statutes that limit the fees that can be charged for medical record requests. Only if you know this you can protest immediately in case the provider tries to overcharge. State statutes may vary from each other and apply generally only to plaintiff attorneys.
- Keep track of each request: The medical record request must progress smoothly if you are to receive the records on time. Factors that can delay the progress include:
- Missing records
- Lost medical record request
- Required payment
- Incomplete authorization information
Keeping track of the requests is the best way to ensure that everyone involved stays informed. Besides, you can also minimize turnaround time. The best part of this practice is that attorneys can avoid the frustration of being forced to retrieve the required medical records at the last moment.
- Ensure that the records are updated: Any record updates must be obtained on time. Add all new records to the medical records that are already categorized.
- Back up all the records: Make sure that all the medical records are safe and secure. If they are hard copies, make physical copies and store them securely offsite. For digital records, you can make a data backup and store it offsite.
- Make sure that you bill the clients: Keep note of which payments were made for which client’s records. You should keep track of each client and each case separately to ensure clarity in billing.
- Partner with an expert medical record retrieval company: Many law firms many not have the resources or infrastructure to perform the medical record retrieval process in-house. Partnering with an expert retrieval service could be a better option. This is because the law firm would be free to accept more complex cases while the expert services provide valuable guidance and assistance in the retrieval process.
Medical record retrieval companies serving attorneys focus on staying organized and have a foolproof process in place to coordinate schedules, meet guidelines, maintain asset and record inventory and facilitate any required travel. This is applicable for an in-house team also if the retrieval process is to be smooth and hassle-free. Communication skills are another vital requirement to interact positively with providers. All parties involved in medical record retrieval have to be properly trained on all guidelines and documentation requirements, and HIPAA as well as other privacy/compliance related regulations.
