D R M O H A M E D M O S A A D H A S A N

M D M P H C P H Q C P P S G B S S

Claims Management

1048697 Compare and contrast claims management activities

with loss prevention activities

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Definitions

Sentinel Event - any unexpected occurrence involving death or serious physical or psychological injury or the risk thereof

Adverse Outcome - a clinical outcome that while

neither desirable nor necessarily anticipated may still

have been a known possibility associated with the

treatment or procedure

Definitions

Potentially compensable event ( PCE ) anoccurrence that may end up with claimsuit withsubsequent payment made by the organization to thepatientfamily

Claim - Formal notification (generally in writing)that monetary damages are being sought for analleged injury

Lawsuit - Formal legal action filed in court

Definitions

Corporate liability it is the legal responsibility ofthe healthcare organization to provide reasonablecare and safe environment to its patientscustomers to provide functioning equipment and supplies andto select all persons who practice within theorganization with care with commitment tosupervise them

Definitions

Insured Parties organization and employeesother organization has agreed to provide coverage

Duty to Defend insurer will defend any claim orsuit alleging injury or damage and seeking damagescovered under the policy

Duty to Pay Damages insurer will pay damagescovered within the policy period

Definitions

Reserves estimates of the amount ultimatelyrequired to settle a claim or pay a judgment(indemnity reserve) and to provide for a defense andpay other allocated expenses related to managing aclaim (expense reserve)

Different kinds of Liabilities

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

1048697 Compare and contrast claims management activities

with loss prevention activities

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Definitions

Sentinel Event - any unexpected occurrence involving death or serious physical or psychological injury or the risk thereof

Adverse Outcome - a clinical outcome that while

neither desirable nor necessarily anticipated may still

have been a known possibility associated with the

treatment or procedure

Definitions

Potentially compensable event ( PCE ) anoccurrence that may end up with claimsuit withsubsequent payment made by the organization to thepatientfamily

Claim - Formal notification (generally in writing)that monetary damages are being sought for analleged injury

Lawsuit - Formal legal action filed in court

Definitions

Corporate liability it is the legal responsibility ofthe healthcare organization to provide reasonablecare and safe environment to its patientscustomers to provide functioning equipment and supplies andto select all persons who practice within theorganization with care with commitment tosupervise them

Definitions

Insured Parties organization and employeesother organization has agreed to provide coverage

Duty to Defend insurer will defend any claim orsuit alleging injury or damage and seeking damagescovered under the policy

Duty to Pay Damages insurer will pay damagescovered within the policy period

Definitions

Reserves estimates of the amount ultimatelyrequired to settle a claim or pay a judgment(indemnity reserve) and to provide for a defense andpay other allocated expenses related to managing aclaim (expense reserve)

Different kinds of Liabilities

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Definitions

Sentinel Event - any unexpected occurrence involving death or serious physical or psychological injury or the risk thereof

Adverse Outcome - a clinical outcome that while

neither desirable nor necessarily anticipated may still

have been a known possibility associated with the

treatment or procedure

Definitions

Potentially compensable event ( PCE ) anoccurrence that may end up with claimsuit withsubsequent payment made by the organization to thepatientfamily

Claim - Formal notification (generally in writing)that monetary damages are being sought for analleged injury

Lawsuit - Formal legal action filed in court

Definitions

Corporate liability it is the legal responsibility ofthe healthcare organization to provide reasonablecare and safe environment to its patientscustomers to provide functioning equipment and supplies andto select all persons who practice within theorganization with care with commitment tosupervise them

Definitions

Insured Parties organization and employeesother organization has agreed to provide coverage

Duty to Defend insurer will defend any claim orsuit alleging injury or damage and seeking damagescovered under the policy

Duty to Pay Damages insurer will pay damagescovered within the policy period

Definitions

Reserves estimates of the amount ultimatelyrequired to settle a claim or pay a judgment(indemnity reserve) and to provide for a defense andpay other allocated expenses related to managing aclaim (expense reserve)

Different kinds of Liabilities

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Definitions

Potentially compensable event ( PCE ) anoccurrence that may end up with claimsuit withsubsequent payment made by the organization to thepatientfamily

Claim - Formal notification (generally in writing)that monetary damages are being sought for analleged injury

Lawsuit - Formal legal action filed in court

Definitions

Corporate liability it is the legal responsibility ofthe healthcare organization to provide reasonablecare and safe environment to its patientscustomers to provide functioning equipment and supplies andto select all persons who practice within theorganization with care with commitment tosupervise them

Definitions

Insured Parties organization and employeesother organization has agreed to provide coverage

Duty to Defend insurer will defend any claim orsuit alleging injury or damage and seeking damagescovered under the policy

Duty to Pay Damages insurer will pay damagescovered within the policy period

Definitions

Reserves estimates of the amount ultimatelyrequired to settle a claim or pay a judgment(indemnity reserve) and to provide for a defense andpay other allocated expenses related to managing aclaim (expense reserve)

Different kinds of Liabilities

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Definitions

Corporate liability it is the legal responsibility ofthe healthcare organization to provide reasonablecare and safe environment to its patientscustomers to provide functioning equipment and supplies andto select all persons who practice within theorganization with care with commitment tosupervise them

Definitions

Insured Parties organization and employeesother organization has agreed to provide coverage

Duty to Defend insurer will defend any claim orsuit alleging injury or damage and seeking damagescovered under the policy

Duty to Pay Damages insurer will pay damagescovered within the policy period

Definitions

Reserves estimates of the amount ultimatelyrequired to settle a claim or pay a judgment(indemnity reserve) and to provide for a defense andpay other allocated expenses related to managing aclaim (expense reserve)

Different kinds of Liabilities

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Definitions

Insured Parties organization and employeesother organization has agreed to provide coverage

Duty to Defend insurer will defend any claim orsuit alleging injury or damage and seeking damagescovered under the policy

Duty to Pay Damages insurer will pay damagescovered within the policy period

Definitions

Reserves estimates of the amount ultimatelyrequired to settle a claim or pay a judgment(indemnity reserve) and to provide for a defense andpay other allocated expenses related to managing aclaim (expense reserve)

Different kinds of Liabilities

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Definitions

Reserves estimates of the amount ultimatelyrequired to settle a claim or pay a judgment(indemnity reserve) and to provide for a defense andpay other allocated expenses related to managing aclaim (expense reserve)

Different kinds of Liabilities

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Different kinds of Liabilities

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Professional Liability

Physiciansindependent Practitioners9

Liabilities of Lack of documentation of treatment

Inadequate work-up (based on accepted

standards)

Acts of others (eg nurses) if exercising control

Failure to attend or follow up

Mistaken identity (along with the institution)

Misdiagnosis if based on inadequate examination

and testing

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Professional Liability

Physiciansindependent Practitioners10

Wrong diagnosis followed by improper treatment

causing injury

Treatment outside field of competence

Abandonment (neglect or failure to follow up after the

acute stage of illness--unilateral termination of the

physician-patient relationship without notice to the

patient)

Failure to obtain informed consent

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Professional Liability

Physiciansindependent Practitioners11

Failure to seek consultation or refer to a medical

surgical specialist

Use of unprecedented procedures unless approved

by a respectable minority of medical opinion

Failure to order diagnostic tests which are considered

to be a matter of common knowledge

Failure to obtain results of diagnostic tests ordered

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Professional Liability

Physiciansindependent Practitioners12

Infections resulting from failure to utilize proper procedures

precautions

Aggravation andor activation of a preexisting condition if

injury results

Premature dismissal or discharge

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Professional Liability

Nurses13

Administration of drugs inconsistent with nurse practice

acts or institutional policies

Failure to follow physicianindependent practitioner orders

Failure to report significant changes in a patients condition

Failure to take correct verbal or telephone orders

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Professional Liability

Nurses14

Operating room spongeinstrument miscounts -Patient

burns

Patient falls

Failure to report defective equipment

Failure to follow established nursing procedures

Negligent handling of patient valuables

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Question

A Physician asks a nurse to cancel EKG for a patientThe nurse forgot to record this cancellation amp thenthe patient died the physician should

1 do nothing since the cancellation is the cause ofdeath

2 ask the nurse to write cancellation in the medicalrecord

3 add an addendum to the record that the EKG hadbeen cancelled

4 the physician add the cancelled order to the record

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

The Concept of Negligence16

Negligence means lack of proper care

Proper care is based on a defined standard established

by law to protect others against harm

In medical malpractice proper care is judged by peers

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

The Concept of Negligence17

Negligent conduct (based on set standards and under like

circumstances and training) is

Doing what a reasonable person would not do (Act of commission)

Failure to do what a reasonable person would do (Act of omission)

Gross negligence failure to act if there is known or

suspected risk resulting in adverse impact or death

Contributory negligence a plaintiffs proven contribution

to hisher own harm

Res Ipsa Loquitur= clear evidence

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Burden of Proof for Negligence(all elements must be proven)

18

Duty The healthcare institution having custody of a patient

must

Breach of duty based on policies or procedures

(advertised standards of care) or reasonable standards of

care set by law regulations or peers Measurable harm

(injury)

Causation The breach of duty caused the injury

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Claims Process

Identification

Investigation

Documentation

Reporting

Reserving

File Management

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Claims Identification and Investigation

Report of an event (formal and informal)

Internal investigation

Guidelines for investigating an event

ndash Discover and document the facts

ndash Secure evidence

ndash Determine the applicable standard of care

ndash Assess the applicable legal principles

ndash Communicate with appropriate persons

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Reserving of Claims

Set aside money to pay indemnity costs and legal fees

Critical for the financial soundness of the insurance company or the self-insurance fund

Reserve set when exposure can be sufficiently assessed

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Litigation Management

Selecting a Defense Firm

ndash Experience

ndash Multiple attorneys capable of handling the case

ndash No clients preferred over others

ndash Billing rates

ndash Geographical proximity

ndash Current caseload

ndash Experience with subject matter

ndash Experience with plaintiff counsel

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Litigation Management

Communicating with Defense Counsel

ndash Acknowledgment of assignment

ndash Designation of trial attorney

ndash Investigation

ndash Medical reviews

ndash Settlements

ndash Reporting requirements

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Litigation Management

Controlling Legal Fees

ndash Hourly rates

ndash Professional services

ndash Miscellaneous expenses

ndash Bill auditing

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Litigation Management

Evaluating Defense Firm Performance

ndash Procedural compliance

ndash Track record

ndash Billing

ndash Understanding of underlying medical issues

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Claims Settlement Process

Negotiate with the claimant if not represented by legal counsel

Negotiate with the claimants attorney if represented by legal counsel

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Question

A potentially compensable event may exist

A In the absence of an injury

B Only in the presence of a physical injury

C Only in the presence of a physical or

psychological injury

D Whenever a lawsuit is filed

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Corporate Compliance

Examples of Fraudulent Activities

ndash False claims and fraudulent billing

ndash Bribes kickbacks excessive or unreasonable

discounts or rebates and profit-sharing agreements

ndash Medical neglect or abuse of a patient

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Corporate Compliance

Why have a Compliance Program

ndash Fulfill a legal duty to ensure false or inaccurate

claims are not being submitted

ndash Demonstrate a commitment to honest and

responsible beliefs and practices

ndash Provide a more accurate view of employee and

contractor behavior

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Corporate Compliance

Why have a Compliance Program

- Identify and prevent criminal and unethical conduct

ndash Improve the quality of patient care

ndash Implement a means for immediate and

appropriate corrective action

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Corporate Compliance

Minimum Compliance Program Elements

ndash Develop and distribute written standards of conduct and

PampPs that demonstrate the organizationrsquos commitment

to compliance

ndash Designate a chief compliance officer and an appropriate

oversight committee

ndash Develop and implement regular and effective employee

educational programs

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

Minimum Compliance Program Elements

ndash Implement and maintain an appropriate confidential

complaint process

ndash Develop a system to respond to allegations

ndash Use audits to monitor compliance

ndash Investigate and resolve identified problems

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit

To sum up

we have discussed

1048697 Distinguish between a claim a potentially compensable event a sentinel event and an adverse outcome

1048697 Describe the four elements that must exist in order for

there to be professional liability

1048697 Discuss the various exposures for different types of

Organizations

1048697 State the critical steps in a lawsuit