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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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andytheman | @andytheman | Aug 23, 2023
In reply to @andytheman "That’s what my insurance company said that if I get a bill because they denied it..." + (show)
@andytheman

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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Well, I finally won my appeal. The request for the payment was sent to the medical department of my insurance company. Supposed to be the Behavioral Health Insurance Program. I’m all set thanks to GeneSight for straightening everything out.

REPLY
ali012 | @ali012 | Nov 20, 2023

Improving incomplete physician notes involves several steps. First, focus on thorough documentation during patient encounters. Include key details, assessments, and treatment plans. Review notes immediately after each session to fill in any missing information. Establish templates or prompts to ensure comprehensive coverage of all aspects of patient care. Continuous training and feedback among healthcare staff can also enhance note-taking consistency and completeness.

REPLY
1 reply
kell4042 | @kell4042 | Nov 20, 2023
In reply to @ali012 "Improving incomplete physician notes involves several steps. First, focus on thorough documentation during patient encounters. Include..." + (show)
@ali012

Improving incomplete physician notes involves several steps. First, focus on thorough documentation during patient encounters. Include key details, assessments, and treatment plans. Review notes immediately after each session to fill in any missing information. Establish templates or prompts to ensure comprehensive coverage of all aspects of patient care. Continuous training and feedback among healthcare staff can also enhance note-taking consistency and completeness.

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Oh I know that, just was wondering how to get physicians to do it. I lost my Disability case due to lack of documentation, I have wrong dx codes in chart, and notes are not being locked for 60 days post visits.

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