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The idea of litigation makes any physician cringe. The fact is that most physicians will get some kind of letter from an attorney’s office at some point during their career. Unfortunately, the case might be regarding a scenario where you did not even see the patient. You may have given an order to another physician, who made the mistake that cost you big bucks.

There are a few things you can do to help your case against any patient seeking to hurt your bank account over an issue that may not even be your fault. Your biggest ally is “documentation.” Without documentation, it is your word against the patient and/or any other medical personnel that may be involved.

There are endless scenarios of what can go wrong and result in a phone call from an attorney’s office. Let’s keep it simple and use an example you might take for granted, such as not getting back to a patient about what you may consider a minor issue. While something may be minor to you, it can be major to the one on the other end. A patient may accuse you of ignoring their situation.

Keep in mind that when something is wrong with you physically and you are feeling pain, five minutes can feel like five years. Patients want to be heard and a rapid response is imperative. It is essential for them to feel important and to know they are in caring hands. When a patient has been with their doctor for many years, they have a connection and feel that physician is their friend. The physician might not see that because they see numerous patients throughout their busy day, but the patient sees one person at that appointment. That person is you. If you betray them in any way, not only will they find another provider for care, which directly affects your bottom line, they might also seek legal counsel.

Don’t make it so easy for someone to accuse you. Give your representation a leg to stand on. If McDonald’s can get sued for someone spilling hot coffee on themselves, a patient can find something that they feel will merit a visit to court.

• Document all telephone calls from the patient. Make a note of when the call was received, by whom it was received in the office, what the call was regarding, and the details of how it was handled including advice, prescriptions, and/or diagnosis. Lack of such documentation can diminish a physicians’ defense if litigation should occur. Always document attempts to contact the patient. What if the patient no longer has the number on file? A certified letter may need to be sent to demonstrate you did everything you could to contact the patient. 

• Have a follow-up/ recall system in place for abnormal labs, making sure the patient comes in for a consultation. Letting a patient know something is normal before they call the office to ask about their results is a nice way to provide better customer service than your competition down the road.

• Be sure that when you or your staff document in a patient’s chart, it is legible.


Any personnel writing in the patient chart must initial their notes with their professional title. For example, MA (medical assistant), RN (registered nurse), NP (nurse practitioner), et cetera. Do not use white-out on any medical records, including progress notes. Corrections are to be made with a single line through inaccurate data with a date, initial, and title.

Keeping information clear within a patient’s charts will not only help with any legal issues that may come your way, it will also be of assistance with any insurance audits in your future. Getting into the habit of proper and detailed documentation will verify your credibility during an audit, which are randomly done. It is only a matter of time before your number is picked out of that enormous hat. Protect yourself from frivolous lawsuits by documenting each encounter you have with your patient. While it may seem like too much to add to your already long list of duties, it is a vital part of your profession that will help you protect your bottom line.



Minerva DeJesus and Audi Reyes founded Simple Solution Billing in Maitland.

Tags:

Auriana Reyes, Minerva DeJesus, RX for the Bottom Line, Simple Solution Billing

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