article thumbnail

Do You Worry About Getting Audited?

Nurse Practitioners in Business

Clinical documentation audits. But it’s not the only reason payers may look at clinical documentation. We all know our documentation can protect us or get us into trouble if it’s not there. How to perform a self-audit prior to submission of any documentation. Or are there liability issues?

Business 370
article thumbnail

Long-Term Care Nurse Fired for Not Falsifying Documentation

Nurse.com

The RN did the assessment and documented her results. The resident was found deceased on the floor the next day, and the RN was asked to change her documentation of her assessment. The administrator had another RN change the documentation done initially by the RN in question. The report was denied by the organization.

Insiders

Sign Up for our Newsletter

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

article thumbnail

How to Conduct Effective Compliance Audits 

American Medical Compliance

The healthcare industry is highly regulated, with various laws such as the Health Insurance Portability and Accountability Act (HIPAA), the Health Information Technology for Economic and Clinical Health Act (HITECH), and the Medicare and Medicaid Services (CMS) regulations shaping operations.

HIPAA 105
article thumbnail

NPs in 2025: Trends to Watch 

Minority Nurse

Those technologies, he said, use a microphone that’s set up in the exam room that is picking up the conversation between the NP and the patient and is not just transcribing the conversation but also putting it into an exam note format would be used for documentation purposes.

article thumbnail

Comprehensive Case Management Training for Healthcare Professionals

American Medical Compliance

The CMS Interim Final Rule The Centers for Medicare & Medicaid Services (CMS) issued an interim final rule with comment period (IFC) to implement section 6052 of the Deficit Reduction Act of 2005 (DRA). As a result, this rule guides how Medicaid will reimburse for case management services.

article thumbnail

Healthcare Compliance for New Providers: Getting Started

American Medical Compliance

CMS (Centers for Medicare & Medicaid Services) These regulations provide essential guidelines for healthcare providers participating in Medicare and Medicaid programs. For example, CMS requires accurate and timely documentation of patient care to ensure proper billing and reimbursement.

HIPAA 105
article thumbnail

The Rise of Malpractice Claims Against NPs

Daily Nurse

Centers for Medicare and Medicaid Services. Document your patient care assessments, observations, communications, and actions in an objective, timely, accurate, complete, and appropriate manner. Remind patients to seek emergency treatment if a condition worsens, and document this action.