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Most hospitals and health systems have invested in Clinical Documentation Improvement Programs in the inpatient setting, now migrating to the outpatient arena. Most recently the professional associations representing the CDI profession have elected to change the name from Clinical Documentation Improvement to Clinical Documentation Integrity. With the name change to Clinical Documentation Integrity, current CDI processes must adapt to actually make headway in achieving real measurable meaningful sustainable integrity in physician documentation that supports both quality of care as well as hospital optimal net patient revenue with preservation. The word “Integrity” in CDI requires CDI to recognize the medical record as a Communication Tool versus a Reimbursement Tool.
Whether by the U.S. Congress or the Mississippi Legislature, there are many rules and regulations in place clearly defining the working relationship between Mississippi healthcare providers and health insurers. But one aspect of the relationship that is unregulated is the issue of what constitutes medically necessary care for purposes of health insurance reimbursement.
This presentation will discuss the current environment and statistics related to healthcare breach, review the need for Covered Entities and Business Associates to develop sophisticated incident response plans, and shed light on best practices for assembling an incident response team, review critical steps for the first 24 hours following a breach, discuss communications strategies for patient notification and outline various approaches for specific incident types.