Medical Records
For workers’ compensation claims, medical records are the basis for determining whether a particular treatment or service is medically necessary and, therefore, reimbursable by your employer’s insurance. As such, each healthcare provider must create and keep medical records documenting a patient’s course of treatment. Unfortunately, however, the cost of sending medical records to a lawyer or other provider can be high.
How Medical Records will Affect Your Case
It is absolutely vital in a workers’ compensation case that good medical records are created and kept. At all phases, everything should be documented. Every time a workers’ compensation claimant sees a physician, physical therapist or other medical provider, to treat a work-related injury, medical records will be used to document the diagnosis, treatment plan, and recovery process.
The Law
Maryland law (Health General Sec. 4-304) allows physicians to charge patients a fee (adjusted annually for inflation) for copying medical records. In 2014, the charges include a fee for copying not to exceed .76 cents for each page of the medical record, and the actual cost of postage and handling. If the records are sent to another provider, there is a preparation fee of $22.88. The federal HIPAA regulations do not allow a charge for a preparation fee for records provided directly to the patient.
As of February I7, 2010, if a medical practice is using an electronic medical records system, they must provide a patient requesting their medical record with a copy in electronic format if the patient so requests. The charge for the copy provided can be no more than the actual labor costs incurred by the practice in responding to that request.
Healthcare providers may not withhold a medical record because the person in interest has not paid an outstanding bill for treatment. However, healthcare providers may require payment of the preparation, copying, shipping and handling fees and charges before turning the records over to a patient or other authorized individual.
Health care providers are required to comply with subpoenas, and no fee may be charged to transfer the records of Medicaid recipients to another provider.
What Medical Records Include
According to the Maryland Workers’ Compensation Commission Guide of Medical and Surgical Fees, medical records should include:
- History of the patient;
- Results of a physical examination performed in conformity with the standard of practice of similar health care providers, with similar training, in the same or similar communities;
- Progress, clinical, or office notes that reflect:
- subjective patient complaints;
- objective findings of the provider;
- assessment of the presenting problem;
- plan(s) of care or recommendation(s) for treatment; and updated assessments of patient’s medical status; and response to treatment or therapy.
- Copies of lab, x-ray, or other diagnostic tests, if any, that reflect the current progress of the patient and response to therapy
- Hospital inpatient and outpatient records, if any, including:
- operation reports;
- test results;
- consultation reports;
- discharge summaries; and
- other dictated reports.
Most healthcare providers must maintain a patient’s medical bills, laboratory reports and X-ray reports for 5 years after the record or report is made. In most cases, the medical record of a minor may not be destroyed until the patient turns 21 or for five years after the record or report is made, whichever is later, unless the patient or guardian is notified. Many providers will send notice to consumers regarding the destruction of records to allow patients to request copies.
Ultimately, not having good, complete medical records can make a good, smooth workers’ compensation case bad. Poor med records can cause delays in compensation or treatment. In the worst case scenario, medical records shortcomings can cause a case to have no compensation.
If you have questions about medical records issues in your workers’ compensation case, please call Warnken, LLC at 443-921-1100. We’re happy to help.