Your Tips on how to improve Incomplete Physicians Notes?

Posted by kell4042 @kell4042, Jul 24, 2023

What to do when physician doesnt/hasn't completed or is lacking documentation?
My short term disability was denied due to lack of supporting documentation. I don't know what to do or how to approach without ruining my rapport with him or his office, but he hasn't been completing sections of summary notes with 80% of important dx, issues, symptoms, treatments, physician notes.
And I'm confused.

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I applied for permanent disability benefits from Social Security and I knew that I needed as much evidence as possible so I just rounded up my doctors and told them why I needed evidence to prove my case.

I know how important it is to have irrefutable evidence due to my law enforcement experience. So I set off to get my evidence and eventually had gathered a whole bunch of evidence including documents.

I sent them to their Boston office and within 3 weeks I received an approval letter. My disability was deemed legitimate and met their definition of an allowable true disability.
That was over 15 years ago. I’m still on it. I can’t say enough regarding irrefutable evidence .
They want written proof of your claim (written on paper).

Don’t fret because right now they are taking a long time for some reason (has to do with politics). But they pay you retroactively. They are refusing and denying somewhere over 90 % of claims the first time around. They figure most people will just accept their denial letter and move on. (Saves money).

There are 3 judges that have to be in agreement to process your claim and make a determination. Has to be unanimous.
Some recommend getting a disability lawyer. I took a chance because I was confident I gave them no reason to deny my claim. It worked without my hiring a lawyer. If your doctors are not providing you with what is actually due you. You’re going to have a problem and will probably need a lawyer to request the information you need. A lawyers letter requesting the information usually should get their attention. Unfortunately that requires a few bucks. You have to decide if the cost is worth more than what you may collect (if anything) from Social Security. The ball is in your court. Don’t worry about offending your doctor (s) , there are ways to get the information they are supposed to have to begin with. There are laws regarding this lack of record keeping. Good luck
Andy

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This is a little off base as to why you posted this, but, I have noticed on my doctor summary notes sometimes there are inconsistencies and inaccuracies as to my visit. I even questioned one doctor about it and I don't think they liked it and they wouldn't answer me back. I just decided to let it be. Anyone else have advice on this? Praying for the above two and your issues. Blessings & Prayers.....

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That's what I'm experiencing. My rapport seems strained and almost won't talk to me at all now

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@covidstinks2023

This is a little off base as to why you posted this, but, I have noticed on my doctor summary notes sometimes there are inconsistencies and inaccuracies as to my visit. I even questioned one doctor about it and I don't think they liked it and they wouldn't answer me back. I just decided to let it be. Anyone else have advice on this? Praying for the above two and your issues. Blessings & Prayers.....

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Yes! Absolutely! And makes me so irritated, mad and frustrated at the lack of attention to important AND significant health-related detail!

At my first dr's visit with a new doctor for me I fot the visit notes at the end of the visit and scanned them, and saw several inaccuracies. The one I recall the most was that (incorrectly) I was a smoker - wrong!!! Not me! ...could affect many things, right? - like insurance rates, and who knows what else?

I pointed it out (politely, of course) and it was removed. But how many people don't read/review these notes? [A lot] ...And what else has been incorrectly/inaccurately put into my record that I may never see but could have impacts? [I, and others, will never know!]

I have come to - with the exception of one upsetting visit - greatly respect my PCP, aside from these mistakes, but there is such a fundamental need for trust in this doctor-patient relationship, and unfortunately - like many, many aspects of our daily lives - this trust is damaged, not cared for, and eventually lost.

The struggle for trust, authenticity and conscientious behavior goes on ...

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Try asking to talk to the billing compliance person. Let them know that you are happy with your care, & your physicians, to start the communication, then explain your situation. Often the cancer care department will have their own billing compliance person, as things get challenged, & denied all the time.

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@brandysparks

Yes! Absolutely! And makes me so irritated, mad and frustrated at the lack of attention to important AND significant health-related detail!

At my first dr's visit with a new doctor for me I fot the visit notes at the end of the visit and scanned them, and saw several inaccuracies. The one I recall the most was that (incorrectly) I was a smoker - wrong!!! Not me! ...could affect many things, right? - like insurance rates, and who knows what else?

I pointed it out (politely, of course) and it was removed. But how many people don't read/review these notes? [A lot] ...And what else has been incorrectly/inaccurately put into my record that I may never see but could have impacts? [I, and others, will never know!]

I have come to - with the exception of one upsetting visit - greatly respect my PCP, aside from these mistakes, but there is such a fundamental need for trust in this doctor-patient relationship, and unfortunately - like many, many aspects of our daily lives - this trust is damaged, not cared for, and eventually lost.

The struggle for trust, authenticity and conscientious behavior goes on ...

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Another reason why it is important to read Doctor's notes on MyChart - and thank goodness we have them now, because who knows how many inaccuracies in the past!!!
I like to respond in MyChart with the corrections - then I have it in writing also. And I will tell the Doctor as well.
I have a complex clinical picture now so it is a real challenge for any doctor to stay up to speed. And when there are mistakes in your records, downstream someone could make a decision that is wrong for you.

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@vic83

Another reason why it is important to read Doctor's notes on MyChart - and thank goodness we have them now, because who knows how many inaccuracies in the past!!!
I like to respond in MyChart with the corrections - then I have it in writing also. And I will tell the Doctor as well.
I have a complex clinical picture now so it is a real challenge for any doctor to stay up to speed. And when there are mistakes in your records, downstream someone could make a decision that is wrong for you.

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I use MyChart for 4 different hospitals several labs, and doctors notes. Very helpful to know what’s going on with you.

My psychiatrist during a recent appointment said that I had good insurance and mentioned the cheek swabbing genetics test.

Trusting that he knew what he was doing 1 went for it. That was almost 3 weeks ago. Yesterday I received a denial of payments to the lab because nobody asked for authorization witch is a must. He didn’t do that.
Error #2 is that the lab is not a member of my insurance plan. I called my insurance company and they said that I may have to file an appeal. Before I do that my insurance company told me that they may not have used my optimum benefits and instead used the medical benefits department and not the behavior insurance department. What do I do if it says that it’s still denied. The psychiatrist told me that I have good insurance and swabbed the inside of my mouth to gather my genetic information used to determine what meds complement my body.
What do I do now? I’m assuming the lab has already performed the lab work so now they need to be paid and I don’t know how much it cost me. Could be more than I can afford.

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@andytheman

I use MyChart for 4 different hospitals several labs, and doctors notes. Very helpful to know what’s going on with you.

My psychiatrist during a recent appointment said that I had good insurance and mentioned the cheek swabbing genetics test.

Trusting that he knew what he was doing 1 went for it. That was almost 3 weeks ago. Yesterday I received a denial of payments to the lab because nobody asked for authorization witch is a must. He didn’t do that.
Error #2 is that the lab is not a member of my insurance plan. I called my insurance company and they said that I may have to file an appeal. Before I do that my insurance company told me that they may not have used my optimum benefits and instead used the medical benefits department and not the behavior insurance department. What do I do if it says that it’s still denied. The psychiatrist told me that I have good insurance and swabbed the inside of my mouth to gather my genetic information used to determine what meds complement my body.
What do I do now? I’m assuming the lab has already performed the lab work so now they need to be paid and I don’t know how much it cost me. Could be more than I can afford.

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Keep filing appeals. For some reason genetic testing is automatically denied by many insurance companies. Mine took 4 appeals, before they finally paid. The genetic testing was needed to determine which chemotherapy drugs would be most effect against my cancer. It’s a ridiculous reality. Good luck.

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That’s what my insurance company said that if I get a bill because they denied it file an appeal. It should be covered she said. Right now I have not received a bill But I messaged GeneSight and the claim filed with my insurance company is under another name. And by googling it that company apparently just got bought out so I only know who filed the claim and it wasn’t GeneSight although they are listed as a Gene lab.

They claim that it’s a $2,000 out of pocket but 95% of people pay $330.00. I’m not paying a dime.
It says I will get a notice if I have to pay over $330. Does that mean that if I don’t get a notice I owe nothing or $330?

My psychiatrist said “oh, you have good insurance “ and broke open the package and I swabbed the inside of my cheeks. I never gave him permission to do that.

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