Medical Transcription Service Company

The federal government is spending more than $22 billion to encourage the creation of electronic health records (EHRs). Medical transcription integrated with EHRs is enhancing clinical documentation practices. However, a federal oversight agency has cautioned that electronic health record technology can make it easier to commit fraud and that there are not sufficient safeguards to prevent this is.

A recent report released by the Office of the Inspector General (OIG) for the Health and Human Services Department (HSS) found that flaws in EHR can lead to overcharging. An online questionnaire was sent to Centers for Medicare and Medicaid Services (CMS) administrative and program integrity contractors that use EHRs to pay claims, identify improper Medicare payments, and investigate fraud. These contractors include Medicare Administrative Contractors (MACs), Zone Program Integrity Contractors (ZPICs), and Recovery Audit Contractors (RACs). The reports were also based on reviews of guidance documents and policies on EHRs and fraud vulnerabilities that CMS and its contractors released for health care providers.

HSS Report Findings

The online survey found that CMS had provided limited guidance to Medicare contractors on EHR fraud vulnerabilities. The other key findings of the HSS report are

• CMS and its contractors had adopted few program integrity practices specific to EHRs
• Few contractors were reviewing EHRs differently from paper medical records
• Not all contractors reported being able to determine whether a provider had copied language or overdocumented in a medical record

How EHR Facilitates Fraud

Here are some examples of how EHR documentation practices could be used to commit fraud:

• Copy-pasting or cloning: This enables users to select information from one source and replicate it in another location. Inaccurate information may be entered in the patient’s medical record and inappropriate charges may be billed to patients and third-party health care payers, when physicians or nurses copy-paste information, but fail to update it.
• Over-documentation: This refers to the practice of inserting false or invalid documentation to create the appearance of support for billing higher level services.

Recommendations of the OIG

The Office of Inspector General reported that CMS and its contractors have not adjusted their practices for identifying and investigating fraud in EHRs. The OIG report recommends that CMS should take the following measures to prevent EHR fraud:

• CMS should provide guidance to its contractors on detecting fraud associated with EHRs and work with contractors to identify best practices and develop guidance and tools for detecting EHR-related fraud
• CMS should direct its contractors to use providers’ audit logs. Audit log data set EHRs apart from paper medical records and could useful to CMS’s contractors when medical records are reviewed

However CMS has agreed with the first recommendation and partially concurred with the second recommendation. The Office of the National Coordinator for Health Information Technology (ONC) that coordinates the adoption, implementation, and exchange of EHRs has contracted with RTI International to develop recommended requirements for enhancing data quality in EHRs. Recommendations include audit logs, access controls, including passwords, and export controls that restrict transferring information. Medicare has reiterated that it is working to develop strong standards for validating EHRs to ensure that patients receive the care they need, while protecting taxpayers from fraud waste and abuse.

With health care reform and the need to deliver excellent patient care as well as ensure compliance with ever-changing industry regulations, healthcare practitioners need to maintain accurate and timely documentation. Even with electronic health records (EHR) being implemented at a rapid pace, medical transcription solutions that integrate with EHR have become indispensable when it comes to ensuring efficiency. Partnering with the right transcription company can boost practice productivity, improve the quality of care, and reduce physician stress.  Here are steps involved in choosing a medical transcription service provider:

• Perform thorough online research. There are innumerable medical transcription companies and choosing the right one can be quite challenging. It would be a good idea to go by references from others who have used the services of a particular company. This will tell you if it is dedicated to keeping its promises. Whichever firm you choose, make sure it can meet your specific needs.

• The experience of the company in question should be checked. It is highly advisable to choose one with adequate experience and a good track record.

• Accuracy and timeliness are the most important things when it comes to medical documentation. Make sure the company has a trained, professional team on the job. If you are a specialist, ensure they have experience in transcribing reports for your specialty. Professional companies have multi-level quality checks in place. They can deliver the completed transcripts within the specified turnaround time which may be 12-hours and 4–6 hours.

• HIPAA compliance is mandatory. Ensure that the company has implemented privacy measures to ensure the security of the patient information they are entrusted with.

With healthcare practices implementing electronic health records, EHR integration is also important. The role of the medical transcriptionist is to help deploy the new digitized patient record system, ensure document compliance and help healthcare provider transition seamlessly from paper records to EHR.

• Last not but not least, see the services are competitively priced. 
  

An established medical transcription firm would always offer a free trial offer of their services to help potential clients make the outsourcing decision.

The healthcare scenario is changing at a rapid pace. According to a survey conducted by American Health Information Management Association and the Association for Healthcare Documentation Integrity, new speech and language processing technologies have set the stage for a fundamental transformation in the way transcriptionists work. It is important that the medical transcription company you partner with offers the flexibility to deal with these changes. As Lynne Thomas Gordon, chief executive officer of AHIMA remarked, “The skills of a transcriptionist – to listen and be detailed - and research-oriented, with a familiarity of medical terminology and disease process – are still in critical need in HIM departments during this time of healthcare transformation.”

With the EHR deadline fast approaching, health care providers are hurrying to digitize their medical records However, ‘meaningful use’ requirements is not just about digitization – it involves basic changes in the way medical information is created, organized, shared and utilized. Electronic health records have transformed clinical workflow and habits. Unlike the dictation and medical transcription set-up, meaningful use of EHR requires the physician to enter clinical/patient notes directly into computer during the consultation. This is proving to be quite a challenge and is depriving physicians of even their leisure time. Some industry experts have recommended that hiring EHR scribes could be the solution. However, this has both pros and cons.

How Medical Scribes Can Help

According to a recent report, studies say that on average, physicians spend eight to 12 minutes per patient filling out the EHR. With long hours spent on EHR data entry, many physicians are losing precious time for patient care and clinical research. This has them turning to medical scribes for documentation support.

A professionally qualified scribe can enter information into the electronic health record (EHR) or chart as required by the physician. Today, there are many institutions that offer training for scribes in specific medical specialty like cardiology, radiology, and so on. Medical scribes can improve the physician’s efficiency and productivity in the following ways

• Entering information into the EHR as directed by the physician/healthcare practitioner
• Assisting healthcare provider in navigating the EHR
• Responding to various messages as directed by the provider
• Locating information such as previous notes, reports, test results, and laboratory results for the purpose of review
• Research of requested information

Hiring the services of EHR scribes benefit physicians in several ways

• Allows detailed and better documentation
• Frees up time to see more patients
• Saves documentation time and effort
• Prevents physician burnout
• Improves the adoption rate of EHR/EMR
• Improves compliance and billing

Likewise, like any new system or practice, medical scribe services also pose challenges

Challenges of Hiring EHR ‘Scribes’

• Physicians may feel uncomfortable to examine a patient or provide a diagnosis in the presence of a third person
• Scribes often change documentation workflows and responsibilities and processes may have to be redefined and restructured
• Scribes in the exam room may cause patients to be less honest. This can affect the accurate diagnosis and treatment, thus impacting the overall quality of care.  
• Accuracy checks performed on the scribed documents may slow down overall workflow
• Scribes without adequate experience and clinical workflow knowledge may cause documentation errors, which in turn, would result in serious issues such as increased costs, decreased turnaround time, billing errors, and so on.

In view of these views, there are still many physicians who rely on a medical transcription company for documentation of narratives and feeds to the electronic health record system.

Medical transcription is one of the most popular tasks in business process outsourcing (BPO). Typically, healthcare practices have to process a large chunk of data each day. Medical transcription outsourcing helps physicians, other medical professionals and healthcare practices to focus on the core tasks at hand.          

How Medical Transcription Outsourcing Can Help

Medical transcription outsourcing to a reliable and efficient transcription firm can help physicians save costs and resources since they have more time and energy to offer the right care to their patients. A reliable service provider can transcribe all their dictated reports on history and physical reports, clinic notes, consultation reports, procedures, ER reports, follow up notes and health reports and send them back within the specified time period. So while physicians go about their regular business, their documentation can be safely, cost-effectively and efficiently handled by HIPAA-compliant medical transcription company.

Medical transcription companies can serve the needs of hospitals, nursing homes, multi-specialty healthcare and rehabilitation centers, outpatient clinics, physician practices, etc. The benefits they gain could just help them treat their patients better.

Transcription Companies Are Equipped with State-of-the-Art Technology

A competent medical transcription company is equipped with the infrastructure required for efficient and precise transcription. They feature telephonic as well as digital dictation options, dedicated servers, high speed Internet, sophisticated encryption technology for security of the transcribed information, and much more. The transcription process is systematic, beginning from the dictation of the file by the physician through the preferred option. The dictated file is then uploaded onto the company’s secure server.

The data is password-protected and allotted to professional transcribers. The transcribers have good language and listening skills, and are also trained in medical conditions and terminologies, and can handle any kind of data. The transcribed files are checked by experienced editors and proofreaders before being delivered to the client through the chosen digital file transfer format. An experienced transcription company will offer a choice of encrypted digital format for file transfer and ensure that the files reach them within customized turnaround time.   

Trained and Professional Staff

Thanks to a team of professional transcribers, choice of dictation options, efficient recording infrastructure and comprehensive quality checks by editors and proofreaders, reliable medical transcription services can ensure up to 99% accuracy in transcription. The transcribers and other staff also undergo periodic skill assessments and training programs to ensure that they can fulfill the needs of healthcare providers.
 
Transcription Services at Affordable Rates

In addition to accuracy levels as high as 99%, established medical transcription outsourcing companies offer their services at affordable rates. In fact, healthcare providers would hesitate to outsource their documentation if it did not help save on their operational costs. A professional medical transcription service provider can help its clients save as much as 30-40% on operational expenses.

Physician practices are under pressure to implement the electronic medical record system by next year. This is posing serious challenges in the documentation of medical records. Improper documentation affects health care quality. Moreover, accurate documentation or medical transcription is the key to surviving RAC audits and preventing reimbursement loss. Here are some important considerations when it comes to ensuring high quality clinical documentation:

• Being timely has a lot to do with quality in patient records. History and physical notes and operative notes need to be signed within 24 hours of the patient visit and medical records, within one week after discharge. Time-based codes require accurate documentation of time.

• Documentation should be made clear and comprehensive, and include all the relevant details. Only an information-rich record allows proper reimbursement and improved patient care.

• Blindly following shortcuts and pick-lists of new digital record is not advisable as it might lead to restricted documentation. 
  

• Expanding SOAP notes would be a good idea and adding additional details in the columns available would help in effectively using the record for future care and for better filing of claims.

• Documenting details without delay at the patient encounter would ensure that important details are not missed out, and is rated a best practice.

• State procedure specifics. In the case of surgical notes, it’s important to specify the approach, all the procedures performed, and any unusual incidents that took place during the surgery. For instance, when it comes to lesion measurements, it is necessary to specify when the measurement was taken and if the measurement is inclusive of the margins. Only this can ensure accuracy in coding.

• In order to avoid health care complications and to be free of unwanted legal issues, it is advisable to perform timely verification of the entered data. Always check for possible errors that might encounter in the records and be sure that they are cleared promptly.

• In addition to verifications, performing internal audits regularly would assure top quality for patient records. Before signing the notes, it is crucial for physicians to take responsibility for the accuracy level.

• Make use of professional medical transcription services. The need of the hour is clinical documentation that is extensive and detailed. Only a team of skilled and trained personnel can handle the complex documentation tasks of your healthcare practice.

To be confident about accurate health documents which pave the way for overall efficiency, proper reimbursement, and survival of RAC audits, busy physicians can rely on a professional medical transcription company. Adhering to best practices in managing health records is sure to boost reimbursement and practice revenue.

Medical transcription outsourcing is probably the most outsourced task in the BPO sector. Outsourcing documentation jobs helps healthcare practices save the resources that would be needed to do the job in-house and also reduces a lot of stress.

Medical Transcription Outsourcing is Vital

In-house transcription could compromise the accuracy and efficiency of not only the transcription but also of the core tasks – which is basically providing adequate and potentially life-saving care to patients. Compromising on the latter results in patient dissatisfaction and can lead to serious legal issues, all of which will harm your healthcare practice. Outsourcing medical transcription to a reliable transcription firm is the right option. It helps reduce the workload of your staff, streamline the overall functioning of your practice, and saves precious resources.  

Comprehensive Transcription Options Available

Reliable medical transcription outsourcing firms offer comprehensive transcription solutions at affordable cost. They are also flexible to the needs of their clients and customize turnaround times too. Outsourcing to the right firm brings down the stress and strain of processing voluminous insurance claims and patient records. Healthcare practices such as hospitals, nursing homes, rehabilitation facilities, outpatient clinics, and independent physician practices can focus more on improving their core services by hiring the services of a medical transcription company.

Outsourcing Eliminates Many Headaches

Hospitals and other healthcare practices are faced with an increasing need to bring down their operating costs in order to hang on and succeed. But they are obligated to fulfill their legal and financial obligations towards patients, and patient records and insurance claims are things that must be managed flawlessly in order to avoid untoward consequences. Experienced medical transcription companies can handle these tasks well and also work in accordance with HIPAA regulations and other important legal norms..             

Advantages of Medical Transcription Companies

Medical transcription companies employ trained transcribers who are familiar with medical jargon and procedures. The right service provider can offer up to 99% accuracy in the transcription. The transcribed files are checked thoroughly by experienced editors and proofreaders to assure such accuracy. Security protocols are strictly adhered to in the work environment as well as transfer of data to ensure that confidential patient information does not fall into the wrong hands.  

Healthcare providers are also offer dictation choices such as via telephone or through a digital dictation machine.   The infrastructure provided by medical transcription services include dedicated servers, flawless and high speed Internet connectivity, and advanced transcription-specific technology and software. Everything is designed to ensure security, precision and speed. Offshore as well as onshore transcription options may be provided.     

Flexibility and Cost-effectiveness Assured

If you are finding it difficult to manage your core responsibilities as well as documentation and procedural tasks, it is high time you outsourced your non-core tasks with a reliable medical transcription company. This will help you take care of your patients better and ensure the success of your medical practice.

Only reliable transcription companies offer HIPAA compliant medical transcription service. Hospitals or healthcare practices must ensure that they are handing over their transcription tasks to a medical transcription company that strictly adherers to HIPAA norms.

HIPAA was formulated to ensure protection of patient identity, health information and individual rights through security measures. HIPAA also ensures that the PHI (Protected Health Information) record is not disclosed. Any failure in maintaining HIPAA standards by the transcription company will have a major bearing on the healthcare practice or physician that has outsourced to that company.  HIPAA compliance is crucial for the following reasons:

• It ensures compliance with medical ethics
• It is a law requirement
• It prevents medical identity theft 
  

MEDICAL ETHICS

Medical ethics involves having respect for the privacy of a patient’s information. A doctor or a hospital or any kind of healthcare practice with a conscience and sense of morality needs to understand that the patient and his/her loved ones trust them with their information.   

STRINGENT LAW

Federal law is very strict with regard to HIPAA, a law that was enacted by the US Congress in 1996. Any violation in HIPAA can bring in serious legal penalties. Violators can be imposed criminal as well as civil charges. If the company you are outsourcing medical transcription to fails in ensuring patient privacy, you, as the doctor or healthcare practice that outsourced the task, will still have to share the responsibility.  

RISK OF IDENTITY THEFT

HIPAA compliance is also important to prevent theft of medical identity. Unless the medical transcription company has steps in place to protect the data they receive to transcribe, there could be a theft of medical identity. Medical documents containing diagnosis of the disease or disorder, details about the patient’s health condition, lifestyle habits that contributed to the disease, prescribed medication, treatment, reaction to the treatment, etc can be acquired and misused by third parties causing serious repercussions for the doctor, the healthcare practice or hospital, and the patient.

Damaged reputation is hard to rebuild. Medical transcription companies that do not ensure HIPAA compliance could cost the physician his reputation, leading to loss of patients and income, and the aforementioned legal penalties. In other words, it means big trouble.  

Potential HIPAA Violations Can Lead to Heavy Civil Money Penalties

In a recent case, a managed care company had to agree to pay the U.S. Department of Health and Human Services $1.7 million to settle potential violations of 1966 HIPAA Privacy and Security Rules. The company had failed to implement appropriate safety measures as required by HIPAA Security Rule for authorizing access to the on-line application database. It had not performed proper technical evaluation when the software of its information systems was upgraded, and did not have technical safeguards in place to ensure that only authorized personnel had access to electronic protected health information maintained in its application database.

Medical practices and healthcare centers have faced such penalties too for not ensuring HIPAA compliance. So take care to assign your transcription tasks only to a medical transcription company that sticks to HIPAA obligations. HIPAA compliant medical transcription service will ensure that such incidents do not happen.

How a Medical Transcription Outsourcing Company Ensures Safety of Patient Information

A reliable medical transcription company will ensure that it has measures in place for ensuring confidentiality and privacy of patient information which is demanded by the HIPAA Act. The measures taken to patient data and medical records by HIPAA compliant medical transcription companies would include:    

• Firewalls and filters for preventing unauthorized individuals from accessing the computers
• Password protection for all the data
• File transfer with high tech 256-bit encryption technology
• 24-hour security monitoring
• Random checks and audits
• Signing of non-disclosure agreement for all the staff dealing with patient information

Before you sign up for medical transcription outsourcing, ensure that the transcription company you outsource to have extensive measures for ensuring HIPAA compliance.

Medical transcription involves the creation of accurate transcripts from the recorded notes of physicians. The transcription process is critical to maintain clear records of a patient’s medical history. These reports help the doctor review the patient’s condition as well as prescribe further treatment.

Medical transcription may be done in-house or outsourced to a third party. Medical transcription outsourcing has a number of advantages which makes medical transcription companies very popular today. The doctor can record his dictation on a digital recorder or into a dedicated toll number provided by the medical transcription company. This recording is converted by the medical transcriptionist into text format, which is later maintained as a medical report of the patient.

Listed below are some of the advantages of hiring a medical transcriptionist:

• It is cheaper to outsource than to perform the task in-house
• The transcriptionists are experienced and skilled to perform the tasks
• The work is completed on time and there is no scope for backlog
• HIPAA compliant medical transcription to keep the patient records confidential

There are many companies and individuals that provide these transcription services. However, it is important to carefully choose a reliable provider. A wrong medical transcript may prove to be fatal for the patients. Hence it is critical that the reports are generated by a reliable transcriptionist.

Before finalizing on the transcriptionist, the doctor or hospital should ensure that the transcriptionist is capable of providing quality output. Consider the factors below when choosing a transcriptionist.

• The ability of the transcriptionist or the organization to meet deadlines
• The security measures adopted by them for security of data
• Transcriptionists should have basic knowledge of medical terminology, sign and symptoms, disease names, medication processes, laboratory and diagnostic processes etc.
• They should be fluent in English and well-versed in format styling and editing
• Ability to make use of selected professional reference materials
• Ability to work with word processing equipment, dictation equipment and transcription equipment

Many transcription companies provide free trials to prospective clients to enable them to evaluate their efficiency. During this free trial you should check the following:

• Infrastructure of the organization and the technology used by them
• Accuracy of final draft
• Turnaround time as well as the capacity to meet deadlines
• Promptness of the staff and their skill to provide technical assistance as well as their dedication to customer service
• The process of maintaining confidentiality and security.

A reliable medical transcriptionist is indeed a great support for physicians and other healthcare professionals.

In today’s rapidly changing environment, medical transcription outsourcing has become popular among medical practices looking to improve their bottom line. Medical transcription is a specialized task that requires the services of a qualified transcriptionist capable of transcribing medical data in a clear and logical form. Primarily, outsourcing benefits healthcare providers by ensuring reduced workload and improved efficiency.

Why Utilize Medical Transcription Service?
 
Medical data essentially includes comprehensive details about patients, syndrome diagnosed; medical tests undertaken, test results and drugs recommended. Only a qualified professional can make sense of complex medical terminology associated with the same. When the complex task of transcription is outsourced, medical professionals can focus more on patient care and research activities. A reliable medical transcription company offering value-added medical transcription services has to be chosen as partner. As an initial step towards improving the bottom-line of a medical practice, it is essential to select a medical transcription firm that offers customized and HIPAA compliant medical transcription services for all medical specialties.

How Medical Transcription Services Can Improve the Bottom-line

Improving the bottom-line means providing the best outcome, and in the case of medical practices the end result is to be measured in terms of practice performance, productivity, revenue and patient satisfaction. Following are the advantages offered by a reliable transcription company that will help improve the bottom-line of a medical practice.

• Excellent quality output: Quality assurance (QA) is a factor which plays a prominent role in improving the bottom line of medical practice. A reputable medical transcription service provider will have in place 3 levels of quality checks offering up to 99% accuracy with good audio.

• Convenient dictation methods: Flexible dictation options such as digital dictation and toll-free telephone make the process of dictation easy and efficient.

• Reduce costs: Outsourcing medical transcription helps to reduce the expenditure in different ways. Usually, the pricing is competitive with up to 40% savings. The cost involved in recruiting transcription staff and installing the required equipment can be saved. The medical transcription company bears all the costs related to health insurance and sick leaves of employees. Infrastructure costs can also be saved as all the major costs are incurred by the service providers themselves. 
  

• 24/7 technical support: This means that you can receive the transcription assistance you want whenever you need it. It will surely improve your efficiency and help bring the transcription up-to-date.

• Improve patient satisfaction: Freed from transcription workload, medical professionals can provide more care to their patients and gain improved patient satisfaction.  

Medical transcription outsourcing definitely proves to be an advantage as it streamlines the entire work of medical documentation and delivers quality results within the time frame specified by the clients. Outsourcing this challenging task can enhance the bottom line of a medical practice provided the transcription firm maintains top quality standards and focuses clearly on its core business activities.

The emergency room is a high stress area for physicians, nurses and other medical professionals. The priority here is to save lives, and procedural but legally obligatory tasks can increase the confusion. When stress and confusion rise there are bound to be mistakes and consequently big trouble for the healthcare practice. Outsourcing the documentation tasks of the emergency room could be the right solution. Emergency room transcription services can really help healthcare providers to cut stress and costs.   

Life Saving Patient Care is What Matters

Efficient patient care is something that must be ensured each time somebody is brought to an emergency room. Busy medical practices often find it a Herculean task to maintain proper and accurate patient records. Emergency room transcription service helps by allowing doctors and other emergency room professionals to focus on providing patients with the much-needed life saving care. Healthcare practices can experience simplified workflow, reduced costs and greater patient satisfaction by opting to outsource their documentation tasks.

Comprehensive Medical Transcription Service

Medical transcription is indispensable for the healthcare industry. Various kinds of reports are generated in an emergency room. There is the ER record which contains patient progress reports, medical evaluations, medical history, chart notes, discharge summaries, physical reports, and so on. Patient symptoms, vitals, physical injuries, and neurological status are some of the things recorded by the intake nurse.

The physician then dictates notes on the treatment necessary to deal with life-threatening injuries (in case of accidents) and primary complaints. One of the other major factors making emergency room transcription indispensable is the fact that handwritten notes are mostly avoided by hospitals since they may not always be legible. Physician dictated notes are transcribed, and is the usual procedure now.  

Ensure Accurate Documentation

Outsourcing emergency room transcription to the right medical transcription company could ensure accurate documentation within customized turnaround time. A trained and expert team can deliver accurate transcripts within the specified timeframe. Medical transcribers at a reliable transcription company can serve all the transcription needs of medical emergency centers and hospitals. They are familiar in the latest transcription software and have comprehensive knowledge about all kinds of medical jargon.  

Benefits of Emergency Room Transcription Services

A reliable emergency room transcription company offers the following benefits:

• Transcripts free from errors
• Customized TAT (turnaround times)
• Secure file transfer options
• Secure 256-bit AES encryption
• Digital dictation and toll-free telephone dictation options
• HL7 transcription interface
• 100% HIPAA compliance
• Competitive pricing
• Extensive quality checks
• AAMT guideline 65 character line billing
• Up to 40% cost savings
• 24-hour service throughout the year

An experienced medical transcription company can deal with documentation for various kinds of medical specialties including pediatrics, geriatrics, pathology, gastroenterology, orthopedics, cardiology, radiology, plastic surgery, internal medicine, and more.

Focus on Treatment and Nothing Else

Let the focus of your emergency room be on treating patients who are seriously ill and not on procedural responsibilities. This is possible with the emergency room transcription services offered by an experienced medical transcription company.