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Best Practices in Document Retention: A Guideline for Remaining Compliant

Posted By: Bret S. Bissey, MBA, FACHE, CHC, CMPE and Sara Low / July 15, 2015

Healthcare DocumentAll healthcare providers should have a document retention policy. These guidelines are important for establishing the length of time an organization must keep different document types and the policy for managing document storage and destruction. Providers should pay close attention to creating a policy specifically for contracts and contract-related documents to ensure compliance (including preserving historical actions taken) and avoid any foreseeable liability, discovery and defense expense or risk related to investigations or audits. However, defining a retention policy for an organization’s contracts can be complicated by different historical practices, a lack of agreed-upon industry standards and regulations and the many different types of documents and records (including physician agreements, employment agreements, vendor contracts, payor contracts or other third-party providers, etc.) hospitals must maintain.

Despite these issues, creating and following a document retention plan is necessary for healthcare providers to remain prepared for inquiries into past business practices.

Benefits of Document Retention Policy for High-risk Agreements

There are many reasons to implement a document retention policy.

These include:

  • Providing information in a timely and efficient manner regardless of the urgency of the request.
  • Meeting legal requirements faster and more cost effectively, reducing discover-related time and expense.
  • Demonstrating proven practices of historical good faith through consistent attention to compliance-focused practices.
  • Adhering to state and federal laws.
  • Keeping compliant with the law, HIPPA and other regulatory standards.
  • Having a single repository of critical documents and contracts for general business purposes.
  • Demonstrating good faith efforts against improper destruction.

MediTract’s Recommendations for Document Retention

We would recommend the retention period be stratified for different classes of documentation. The longest period would be documents with the potential to have regulatory compliance exposure. MediTract strongly encourages hospitals to consider longer retention periods due to the costly nature of audits and investigations when information is not readily available.

The look-back period for most investigations is six to seven years at the time of subpoena or initiation of investigation, but this can be extended when the investigation process takes several years. For example, a subpoena issued in 2010 could look back to 2003. However, due to the time it takes to complete investigations and/or associated legal proceedings, documentation can be valuable to have available beyond seven years. In rare, egregious cases, the federal government could look at activity for 10 years.

Given the magnitude of regulatory fines and penalties associated with the violation or accused violation of STARK or anti-kickback status related to specific “referral related” contracts, such as focused arrangements, we recommend longer documentation retention for those contracts and all supporting documentation.

Bret S. Bissey, MBA, FACHE, CHC, CMPE

Prior to joining MediTract, Mr. Bissey was the SVP, chief ethics and compliance officer at UMDNJ, where he successfully led the compliance program to adherence with a rigorous five-year Corporate Integrity Agreement with the DHHS/OIG that occurred following a Deferred Prosecution Agreement. Prior to UMDNJ, Bissey served as the director of the Regulatory Compliance Practice at IMA Consulting, the chief compliance and privacy officer at Deborah Heart and Lung Center (operating under a CIA) and the VP of compliance at Cabot Marsh/QuadraMed. Mr. Bissey earned a Bachelor of Science in business administration and marketing from Shippensburg University of Pennsylvania and an MBA in marketing and healthcare administration from Wilkes University. Mr. Bissey is a frequent national speaker on healthcare compliance and is the author of The Compliance Officer’s Handbook. He is a Fellow of the American College of Healthcare Executives and a member of the Health Care Compliance Association (CHC), American College of Medical Practice Executives and the Healthcare Financial Management Association.

About the Author: Sara Low

Sara Low

As the senior director of business services for MediTract, Sara Low leads the account management team and works to ensure the successful delivery and mediation of our products and services. She is an active participant in client advisory services and is also instrumental to product development, bringing the needs and interests of clients to the technology team. Prior to joining MediTract to head business services, Ms. Low worked with Erlanger Health System to revitalize and oversee its contract management processes. She has 12 years of legal experience and eight years of healthcare compliance experience. Ms. Low holds a Bachelor of Science in legal studies from the University of Tennessee at Chattanooga.