How Documentation Gaps Lead to Liability

The Impact of Accurate Documentation: Real-World Examples from an OIG Audit The importance of accurate condition capture and documentation in risk adjustment cannot be overstated. A recent OIG random review of EmblemHealth highlights just how much is at stake when conditions are incorrectly reported—or overlooked entirely. Here are three patient scenarios uncovered in the audit: Enrollee A • Submitted HCCs: 3 • Validated HCCs: 2 • Review Findings: The submitted HCC for Polyneuropathy was not supported by the medical record. • Impact: $1,992 overpayment to the plan. Enrollee B • Submitted HCCs: 2 • Validated HCCs: 2 • Review Findings: While the submitted HCC for Diabetes Mellitus (DM) with complications was not supported, the documentation did validate DM without complications. • Impact: $2,328 overpayment to the plan. Enrollee C • Submitted HCCs: 2 • Validated HCCs: 4 • Review Findings: Reviewers not only validated the submitted HCCs but also identified two additional HCCs that had not been submitted in claims. • Impact: $4,438 underpayment to the plan. The Takeaways The OIG review illustrates several key themes: 1. Documentation Gaps: Unsupported conditions can lead to overpayments, exposing plans to potential financial penalties and compliance risks. 2. Missed Opportunities: Inaccurate or incomplete submissions may result in underpayments, reducing the resources available to care for complex patients. 3. Importance of Proactive Reviews: Comprehensive reviews of documentation and coding practices can identify discrepancies before they escalate into larger issues. A Path Forward: Best Practices To mitigate risks and ensure accuracy: • Train Providers Continuously: Reinforce the importance of detailed documentation that supports all submitted diagnoses. • Conduct Pre-Bill Reviews: High-risk HCCs should undergo additional scrutiny before claims submission. • Leverage Retrospective Audits: These reviews can identify and address both unsupported claims and missed conditions, ensuring accurate risk scoring. The financial and compliance stakes are high. The EmblemHealth review revealed a $552,000 overpayment recommendation from the OIG, with 25% of submitted conditions unsupported by medical records. On the flip side, 65 additional conditions were identified but not submitted, representing missed opportunities for accurate risk adjustment. In risk adjustment, accuracy is everything. How does your organization close the gap between documentation and coding? Let’s connect and share strategies.

The Documentation Paradox in Emergency Medicine Malpractice "If it wasn't documented, it wasn't done" - a phrase that haunts emergency physicians working in overcrowded departments. The reality I've observed as both an expert witness and practicing emergency physician: Documentation quality inversely correlates with department stress levels, creating a perfect liability storm. The paradox explained: • When care is most complex, documentation time decreases • When patient volume is highest, charting gets delayed • When critical thinking is most important, documentation becomes more templated • When communication is most crucial, it's least likely to be recorded For defense attorneys: Contemporaneous notes about department conditions provide essential context for documentation gaps. The standard isn't perfect documentation—it's reasonable documentation under the circumstances. For plaintiff attorneys: While system pressures are real, they don't eliminate the need for essential documentation of critical assessments and decision-making rationales. My balanced assessment: Emergency physicians must document key clinical reasoning and critical reassessments despite system pressures, but documentation standards should reflect the realities of emergency practice. Risk mitigation strategies that work: • Focused documentation of critical decision points • Brief contemporaneous notes during high-volume periods • Clear documentation of reassessments for boarded patients • Transparent recording of department conditions affecting care What documentation issues have you found most significant in emergency medicine cases? #MedicalMalpractice #EmergencyMedicine #HealthcareLaw #RiskManagement

Unfortunately, It’s already too late… “Who signed off on this?” “When was this last checked?” “Why wasn’t this flagged sooner?” These are the questions that come after an accident. After something goes wrong. After an audit. And the worst answer of all? “We thought it was done.” Safety isn’t just about good intentions, it’s about verifiable action. Can your team: → Show who completed each task? → Prove when it was done? → Retrieve that record instantly? If not, you don’t just have a documentation gap, you have a liability. Accountability starts in the field, the floor, the checklist. It’s not about blame, it’s about building trust. Before the questions come.