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.

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.

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.

Designed to provide secure, auditable and confidential results, professional HIPAA compliant medical transcription services at MTS ensures legal compliance and patient privacy. The company’s HIPAA compliant transcription services ensure confidentiality of patient information, increased efficiency and streamlined process workflow. It offers higher accuracy for the transcribed data and allows safe handling of the medical records.

With its extensive experience in providing physical therapy medical transcription services, the company serves therapists and doctors in private practices, medical clinics/centers and regional hospitals.

Stringent measures and security policies are in place to ensure that the patient records stay safe. Proven measures include –

• Password protected computers
• Secure file transfer
• Daily updated Firewalls and antivirus software
• Audits and random checks
• Regular Windows updates

The right medical transcription team is crucial to handle the job efficiently and the entire team at MTS is trained on HIPAA privacy, security and confidentiality. They can transcribe any physical therapy document including - referral letters, consultation notes, chart notes, follow-up notes, procedure notes, letters and discharge summaries among others.

High level accuracy is crucial for transcripts. All medical transcripts at MTS are taken through three level quality checks to provide 99% accurate outputs.

Physical therapists prefer transcription services from MTS due to advantages such as affordable pricing, flexible dictation options, fast turnaround time, EMR system, and HL7 transcription interface.

“We understand the importance of maintaining the confidentiality of all patient related records in physical therapy clinics as well as other specialties, and have implemented excellent security measures to safeguard sensitive data. To monitor all compliance activity with HIPAA, we have our HIPAA officers with relevant experience in the field. Our HIPAA compliant transcription services are available at an affordable rate, where you save 30 to 40% on your total operation costs,” says a company spokesperson.

Medical transcription services are provided by a medical transcription company and involve the transcription of dictations recorded in the voice of a medical practitioner. Accurate transcripts of these dictations are necessary because the future care provided to the patient depends on the information provided in these documents. Accurate documentation is also important from the point of view of appropriate claim reimbursement.


Medical Transcription Services – Useful to Healthcare Service Providers

It is easier and faster for a medical practitioner to record the medical history of a patient by dictating the details rather than writing it by hand or typing it. This recorded audio clip is handed over to the medical transcriptionist to convert into text format. This service is indispensable to doctors, hospitals, medical care centers and other healthcare providers as the record made is used as reference for the review and continuation of treatment of a patient.

Apart from typing the document as per the audio clip received, it is the duty of the medical transcriptionist to correct spelling errors, diction errors etc. All reports prepared by them have to comply with the law and medico-legal concerns as well as the policies applicable to the healthcare entity.

With these services, doctors and the management staff of hospitals are relieved from the time-consuming work of transcription. When the medical transcription requirements are taken care of efficiently by an outside provider, healthcare entities can focus on care provision for their patients, which in turn enhances the reputation and growth of the hospital too.

Also, there is always a chance of the old staff resigning from the hospital. This would require training the new staff which is again resource-draining and time-consuming. Hence, it is a practical option to entrust transcription to a medical transcription company that will do its job irrespective of changes happening in your organization.

Should Medical Transcription be Outsourced?

Today more and more medical entities are opting for medical transcription outsourcing. Apart from the convenience offered, healthcare providers stand to benefit from the real professionalism and capability of the transcription staff. Usually, reputable outsourcing companies assign a dedicated team to each client to make sure that individual client requirements are met and the work is carried out to perfection. Accuracy and quality are ensured for the final transcripts. Such firms are HIPAA compliant and have excellent security measures to protect patient data. The best thing about associating with a reliable company is that they can meet any challenging turnaround time requirements. This means that you have the transcripts ready whenever you need them, so that your medical documentation stays up-to-date. Your patients have no cause to complain, and accurate documentation will also help you submit timely claims and get the proper reimbursement. Undoubtedly, medical transcription companies provide a great service to healthcare providers with personalized solutions catering to each client.

Picture a busy hematologist. He has to deal with the diagnosis, treatment, and prevention of blood diseases. Specialized in the study of blood, the blood-forming organs, and blood diseases, he would have to provide treatments relating to fields such as internal medicine, physiology, pathology, clinical laboratory work, pediatrics. Hematologists also specialize in oncology. It’s no wonder that all this leaves this healthcare specialist with little time for documentation which is an integral office procedure when it comes to continuity and quality of care and medical billing compliance. Many hematology practices are finding that outsourcing hematology transcription to a professional medical transcription company is the solution. Many benefits can be expected with the right choice of service provider:

• Benefits of Economies of Scale: In-house transcription can prove expensive for an individual medical practitioner. In addition to a professional team, the office would have to invest in the technology and software necessary to carry out transcription. Outsourcing to a professional medical transcription company would help hematologists to enjoy the benefits of economies of scale. Established service providers with a vast clientele would have all the specialized resources necessary to carry out the documentation procedures and can provide transcription solutions at affordable costs. A hematology practitioner can expect considerable cost savings by outsourcing to the right service provider. Established companies help their clients save up to 30 – 40 % on their operational costs.  
  

• Assured Accuracy: Only a professional hematology transcription service provider would be able to handle transcription efficiently. With an objective to provide quality based transcription services, a reputed medical transcription firm employs highly qualified and skilled transcriptionists who are well versed in the important terminology related to hematology such as for example, ‘eosinophil’, ‘erythrocyte’, ‘erythropoietin’, ‘hematopoiesis’, ‘myelogenous’, ‘thrombectomy’ and much more. They would also be aware of important hematology procedures such as hematologic malignancies, immune cytopenias, bone marrow transplantation, biological therapy, stem cell and many other hematology conditions. Getting these terms and procedures right is crucial to the applicability of the transcripts.  Only qualified and expereinced medical transcriptionists would be able to prepare accurate hematology documents in time to meet the hematologist’s requirements. With stringent QA processes, a professional company can ensure transcripts with accuracy rates as high as 99%.

• Document Flow Management System:  Individual hematology practitioners would benefit from the document management software that their service provider offers as part of the transcription process. This helps them in tracking and monitoring their files during the transcription process.  A reliable service provider would also offer feeds to EMR, helping hematology practices in the progress towards the mandatory electronic health record (EHR).

• Customized Turnaround Time : With the right hematology transcription outsourcing partner, a hematology practitioner can expect their transcribed documents to be delivered within the specified time limit.

• Free Trial: Reliable service providers would offer their potential clients a free trial to check out the accuracy and timeliness of their services.

Taking into account security considerations with regard to patient information, a professional transcription firm would abide by all HIPAA regulations.  In addition to a secure work environment to prevent unauthorized access to patient records, the company will have safe modes to protect the confidentiality of medical records and reports as they are transferred through the Internet from the medical office to the transcription company and back.

Outsourcing hematology transcription is therefore a feasible option if you do not have or cannot invest in in-house transcription.