Claim File and System Documentation Part 2

Sunday, December 8, 2002 | 0

The first part of this article series reviewed why file documentation is important, and the different types of people that will review your file documentation (and why). Now we'll discuss the different kinds of file documentation, why it is necessary, and what it should include. The last article in this series will review preparation of status reports and planning for your agent meeting.

Different Kinds Of Documentation

The claim file is comprised of different types of documentation, and the differences account for different handling and disclosure status.

You might be documenting progress and activity notes or you could be documenting specific file issues with an action plan. Your understanding of these differences is critical because a mistake in documentation can have significant consequences both inside, and outside, the claim. Knowledge is power, so your understanding of these differences, including "what" and "where" to document is crucial.

Your company may have multiple claim systems in use. It's important to understand what these systems do, and why they are in place because where you document the issues in the paper file or the system may vary by account and claims system. Nevertheless, there are common guidelines that we all must follow.

Progress/File Notes

Progress file notes should summarize all reports and correspondence on a file. These notes are a chronology of the events that take place during a claim's life.

There may be different categories for different types of notations, so check with your Supervisor on what specific categories are to be included. In addition, depending on your jurisdiction, some of these may need additional editing or placement in different sections of the file or computer system:
- Medical reports
- Investigation reports
- General correspondence
- Legal correspondence
- Vocational rehabilitation reports ( depending on jurisdiction)
- Home Office reports
- Reinsurance reports
- Bills
- Phone calls and what was discussed
- Information left in a message for the other party

Confidentiality Of Medical Information

Medical information is sensitive, and is the subject of a myriad of different state and federal laws. Some types of information are strictly confidential (such as a person's HIV status), and other information may be disclosed to third parties without consent (such as age, gender, etc.). Your company will have guidelines as to what is and isn't confidential medical information, where it should be documented, and how (or when) it should be disseminated, if at all.

Check your jurisdiction for regulation guidelines regarding confidentiality of medical information. Most jurisdictions strictly limit medical information which may be disclosed to the employer.

Do not document your treatment plan in your system or claim file "action plan" category if state guidelines don't allow release of medical information. The system or "action plan" information can be released to the employer, typically on request, so if confidential medical information is in that section you may unwittingly be violating the law. Therefore you want to document your treatment plan in the "medical" category of your claims system or that part of the file that is not subject to release without further legal process.

The Issue Analysis and Plans of Action

An issue analysis should outline the major file issues that are pertinent at the time of your periodic file review. When you focus on creating an analysis that outlines the outstanding issues, you reinforce a proven business approach that will impact and control the "flow" of money that is paid out in benefits.

After you have identified the issues, you need to formulate a plan of action. The action plan should provide a solution and/or strategy with specific timeframes for completion. However, you want to avoid a list of "things to do" which does not address issues. That is why it is important to identify the issues first. The action plan focus is intended to document your thought process and how you will resolve the issues and move the file towards closure .

The timeframes and forms that are required for both the issue analysis and the action plan may vary from office to office and by account. Check with your Supervisor or Manager, or consult your company's "Best Practices" manual for office and account criteria.

Additional Guidelines/Helpful Hints

There are several "details" that will ensure the successful documentation of the claims file. While some of these are obvious, all of these are important to convey your professionalism to the person that ultimately reviews your notes. Remember, your reputation lives well past your handling of the claims file, so be sure to put your best foot forward:

- All entries must be dated with your full name so there is no confusion as to whether "J Smith" means John Smith or Joan Smith.
- Be sure to include the full names and phone numbers of people called.
- Use standard abbreviations; don't make up your own otherwise no one else will understand what you were writing about. Check your guidelines before using any abbreviations as they may not be acceptable in the file or claims system.
- When summarizing medical reports, include the date of the report, the name of the doctor who wrote it (specify defense, applicant, QME, PTP, etc.), and a summary of the pertinent information that affects the claim.
- When summarizing correspondence, include the date of the correspondence and the name and title of the author and a summary of the pertinent information.
- Be concise and objective.
- Avoid descriptive comments and editorializing.
- Avoid negative comments about the employer.
- Don't comment on the previous file handling.
- Edit yourself for neatness, spelling and grammar - look professional.

The final article in this series will look at agent status requests and reports.

Stick to the FACTS!

Author, Cyndi Koppany, is Director of Corporate Training for Cambridge Integrated Services Group, Inc. E-mail her at ckoppany@earthlink.net.