Importance of Retaining Medical Records

1. Importance of Retaining Medical Records Medical Billers and Coders

2. The most important reason for retaining medical records is to share information on a patient’s care with other healthcare professionals. The COVID-19 pandemic and increased inpatient telehealth services have emphasized the importance of retaining complete and accurate records. Retaining well-maintained patient records helps medical professionals ensure continuity of care and protect against any future professional liability claims. The availability of accurate records also provides protection against licensing board complaints and peer review inquiries and can help when responding to investigations by governmental compliance agencies. The potential for billing audits by the Centers for Medicare and Medicaid Services (CMS) or commercial insurance carriers provides further motivation to create and store complete documentation.

3. Applicable Laws Federal legislation such as Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health (HITECH) have also added new requirements for medical and dental records. HIPAA privacy regulations, for example, require that documents created in compliance with the Privacy Rule, such as policies, procedures, and accountings of disclosures, be retained for six years from when the document was created, which follows the federal statute of limitations for civil penalties. The healthcare professions have primarily been regulated by the states rather than by a federal oversight agency. As a result, record retention laws and regulations differ from state to state, so it is important to check and follow state requirements.

4. To summarize As discussed, you must follow your state’s specific guidelines or laws. Where no statutory requirement exists, we recommend the period for retaining medical records as Adult patients, 10 years from the date the patient was last seen; Minor patients, 28 years from the date of birth; Deceased patients, five years from the date of death. Once a record has been destroyed, it is difficult, if not impossible, to defend a case. We encourage medical and dental professionals to consult with their legal counsel regarding how the law in the jurisdictions relevant to their practice has been interpreted by the judicial system. You can also check any signed managed care agreements or contracted healthcare plans to ensure compliance with the record retention requirements of those agreements. 

5. Email : info@medicalbillersandcoders.com Fax no: 888-316-4566 Toll Free no: 888-357-3226 AddressWilmington, 108 West, 13th street, Wilmington, DE 19801Texas, 539 W. Commerce St #1482 Dallas, TX 75208