Your Medical Records. How Correct? How Important? How Damaging?
M.J. McKeown, MD, FACOG, FACS
It begins with our first breath as we receive our APGAR score indicating how healthy we are when we are born.It ends when someone assigns us a diagnosis as we breathe our last.This is our Medical Record
It is the records kept by health practicioners we have seen. It is records kept by various hospitals we have been patients in. It is records kept by private or government insurance agencies that we have been financially responsible for our interactions with the health care system.
The most important but least known is the Medical Information Bureau where health insurance companies collaborate to create a unified record of a person's interactions with the health care system.
A new law just passed by Congress will allow banks, brokers and insurance companies to share consumer information. It will be possible for your health record to shared among all these businesses. I have reviewed Medical Information Bureau records and detailed comments in certified letters to the various companies.
Can these multiple records contain errors? Certainly they can! Can these errors affect one's health care insurance coverage, or ability to get life insurance, or ability to get a job, or ability to receive medically correct treatment? Certainly they can!
- Some examples are in order. These are real events that happened to patients in my practice.
- - First, there was the case of a woman in her thirties who was given severely restricted health care coverage. Her MIB files contained a benign diagnosis from several years earlier and the insurance company was not going to cover any problems with her female reproductive or urinary system.
- Second, was a woman in her forties who was denied any coverage for health care because of her MIB file. Some of the diagnosis went back more than 10 years and all were benign conditions.
- Third, was a woman in her fifties who wa denied life insurance because of data in her MIB file.
All of these were eventually satisfactorily resolved but each one required my review of the MIB records and then detailed comments in certified letters to the various companies.
I am sure that no employer would dare admit it but if a review of the MIB file on a proposed new hire revealed some potentially long term disability it is likely the person would not be hired. The new laws passed by Congress that allow banks, brokers and insurance companies to freely exchange all this information will enhance their ability to combine skills profiling, economic profiling and health profiling. We can only imagine what this will do to approval of loans, mortgages, health insurance, life insurance and to hiring practices.
How do errors occur and what kinds of errors might these be? Errors can occur because of simple coding errors. Errors can occur because of simple transcription errors. Errors can occur because of diagnosis "gaming" when an attempt is made to justify insurance payment in this new world of managed care.
The way errors occur can be entirely innocent mistakes in coding or transcription. There is another source of "errors" that has arisen directly from the structure of managed care. The rules now say that in order for a claim to get paid there must be a match between certain diagnoses and certain treatments or tests performed. There is little uniformity of these "allowables" between companies and this makes it worse. It is thus possible that to enable payment for your care from your insurance company the health care provider system will assign a diagnosis to you that will "allow" the exam or the test or the treatment to be "covered" so you don't have to pay or in some instances so the exam or the test or the treatment can be done at all.
How does one individual obtain information about their medical records to see if they seem to be "correct"?
You just ask! But who you ask and how you ask and what you ask for will make your queries more or less successful. It is well established legally that the information in the medical record belongs to the patient. However the physical record itself belongs to those person or persons who created it.
When asking for information regarding one's medical record attention must be paid to the medico legal climate that exists in the United States. Health care providers at all levels are worried about the possibility of malpractice litigation. It is quite likely that requests for medical records will raise anxieties in those from whom you are requesting information. I would think it would be wise to confront this problem early in your requests and assure those from whom you are asking information that you do not intend to use it in litigation against them. However if such litigation is your intent then you should be open and honest about that and let your attorney make any record requests.
What should you ask for? The complete medical record can have hundreds of pages and much information you don't need to bother with in a review of your medical record. You are most interested in what diagnostic labels have been given to you. You would also want to know the operative diagnosis in the case of any major operation. If tissues were removed from your body and sent for pathology analysis you will want to know those pathologic diagnoses.
Who do you ask and how do you ask? Remember the medico legal climate. You should ask your personal primary physician and you should do it in person. You should make mail inquiries to the medical records section of any hospital or surgical center where you have been a patient. You should make mail inquiries of any health care provider other than your primary personal physician.
What should you ask for? You should ask for the diagnoses and diagnostic code numbers that were given to you at the time of any patient visit, or operative procedure or associated with any pathology report.
- Now to summarize:
- 1. Ask for diagnoses and diagnostic code numbers that were given to you at the time of any patient visit or operative procedure or pathology report.
2. Ask in person to your primary care physician and any other health care practitioners that are currently taking care of you.
3. If the information is not forthcoming in a reasonable time then ask for it by letter and send it certified mail with return receipt.
4. As for the information by letter to all other health care Practitioners, hospitals or surgery centers involved. Send them by routine mail initially. If the information is not forthcoming in a reasonable time then ask again by certified mail with return receipt
The Medical Information Bureau is a special case. This is a large database maintained by the insurance companies. You are entitled to a copy of their files on you. I think it advisable to request this and to review it every year. It may be necessary to get a form from them that your physician will send to them and then the MIB would send the information to him/her and he/she will give it to you.
Medical Information Bureau
P.O. Box 105 Essex Station Boston, MA 02112
(617)426-3660; follow voice mail instructions.
Procedure: Request disclosure form D-2 Cost: $8.00
MIB 330 University Avenue
Toronto, Ontario M5G 1R7
Medical Information Bureau http://www.mib.com/
I would suggest that a person obtain this information as soon as possible and then keep it on file. It would be prudent to update these files once per year.
- What do you do if you think some of the information is incorrect?
- - First, have it reviewed by a friendly health care professional to be certain it is wrong.
- Second, if the information seems wrong after such a review one should contact whoever or wherever such information was obtained and request a review and correction. If simple telephone requests do not provide results then inform them by letter sent by certified mail with return receipt. If certified mail requests do not produce the necessary changes then seek legal help.
- - Make pleasant requests in a non threatening fashion for initial contacts.
- Request diagnoses and diagnostic codes. It is usually not necessary to review the entire medical record.
- Make written requests, if necessary, with polite yet firm letters sent by certified mail with return receipts.
- If all else fails seek legal help.
Remember: Your medical records are important and information in them can affect your ability to get health care or life insurance and may even affect your ability to get a job or financial assistance. Correcting them if they are in error will only occur if you get actively involved. Medical records are supposed to be reviewed before they become official but errors of many types can occur.