What You Should Know Proprietary and Confidential Proprietary and - - PowerPoint PPT Presentation

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What You Should Know

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A New Medical Liability Crisis The medical liability situation worsened in the late 1990’s

 Minimal reforms of 1995 failed  Mandatory rate roll backs were not supported by

the ineffective reforms

 Payouts were out of control  Carriers were going out of business or leaving the

state

 JUA grew to record numbers

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2003 – When Pigs Flew & Chicken Had Teeth House Bill 4 was the name of our 2003 Tort Reform bill

 Signed into law June 11, 2003 by Governor Perry  Took effect September 1, 2003  Touted nation-wide as the model of effective tort

reform

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Still Effective After 10 Years +

 Miraculous accomplishment considering the

magnitude of the bill

 Passing the constitutional amendment assured us

that the courts would not, in prompt fashion,

• verturn the noneconomic caps, enabling insurers

to provide immediate rate relief

 The law was so well written, with language

provided by attorneys who actually try malpractice cases and handle their appeals, that unlike many other similar laws, it has stood the test

• f time and judicial review over and over.

WE NEVER SAID MEDICAL CARE WOULD BE CHEAPER Our goal was to improve access to medical care, and our tort reform has done that.

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Slide supplied by Jon Opelt - TAPA

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Slide supplied by Jon Opelt - TAPA

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Why Do We Have Lobby Teams?

Why not just let TMA and TAPA handle it?

 While our needs are generally consistent with

theirs, priorities can be different. Sometimes someone else is needed to take on the battle.

 “Two heads are better than one” etc  “It takes a village…” -Old African Proverb  We might not know of issues without someone

who is on the political scene regularly telling us

 Like we know about med mal – lobbyists know

about government and politics!

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TMB and Pain Management

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Pain Management Rules

Rule 170 establishes a standard of care not “reasonable physician” standard Keeping pain at satisfactory level and patient functional not sufficient TMB thinks long term narcotics do not work Rule 170 sets out specific steps

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Needed Revisions:

1.

Remove emphasis on urine drug screens – expensive and destroys trust

2.

Allow for a treatment goal of stability rather than “progress toward treatment goals”

3.

Eliminate requirement to document “effect of the pain on physical and psychological function”

4.

Mid-levels can prescribe, but refills need consult with physician - backwards

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"In my many years I have come to a conclusion that one useless man is a shame, two is a law firm, and three or more is a congress." JOHN ADAMS

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Risk Management Services

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Risk Management Department

TMLT’s risk management department is dedicated to providing policyholders with comprehensive services to assist in the avoidance, reduction, and defense of medical liability claims, as well as Texas Medical Board complaints and privacy regulation violations. The risk management department offers continuing medical education programs, practice reviews, telephone/e-mail consultations, and sample resources enabling physicians to reduce their risk. Services are customized to policyholder needs and the rapidly changing healthcare environment physicians practice in today.

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Risk Management Services

Continuing Medical Education

 CME seminars  On-line CME activities  CME publications

 Medical record review and practice evaluation  Personalized wrap-up discussion  Customized, specialty-specific recommendations

 Phone/E-mail consultations  Sample tools  Practical resources

Practice Reviews Consultations & Resources

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CME: Accreditation with Commendation

TMLT has achieved Accreditation with Commendation – the ACCME’s highest level of recognition

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CME: Popular Program Topics

• Describe physician responsibility related to

informed consent and areas of vulnerability inherent in informed consent

Informed Consent

• Identify when a physician-patient relationship

has been established and develop strategies to appropriately terminate

Patient Termination

• Recognize “hot buttons” arising in post

tort-reform litigation and complaints to the TMB

Texas Medical Board

• Assess compliance level with privacy

protections under HIPAA and address new protections afforded to Texas patients

HIPAA

• Address how EMR’s impact patient

safety, quality reporting, and risk management

Electronic Medical Records

Ethics CME

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CME options at your fingertips

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Practice Reviews

The Risk Management Department has Texas covered

During a practice review, a risk manager will:

 Tour and assess practice  Review medical records for

strengths and weaknesses

 Review policies and procedures  Meet with physicians to discuss

findings and recommendations

 Prepare a written

recommendation report and assess responses

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Practice Reviews: Common Recommendations

• Templates should be edited as

necessary to ensure record accurately reflects care delivered

Preformatted Text

• r Templates
• Prompt completion of patient encounter notes

provides protection from perception that note could have been altered

Locking Encounter Notes

• Duty of providing informed consent lies

with provider and should be documented in the medical record

Informed Consent

• Education of any form should be documented

to verify patient was provided pertinent information regarding care

Patient Education

• Standardization in critical areas limits

miscommunication and enhances training

Policies and Procedures

EMRs

Documentation

P&P

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Consultations and Resources

A risk management representative is available daily for confidential phone or e-mail consultations and to provide resources regarding risk management issues, such as:

 Termination of the physician/patient relationship  Release of medical records  Treatment of noncompliant patients  Texas Medical Board rules  Treatment of minors

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Medical Director Coverage

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Definition

L. "medical director" means a physician who serves in an administrative capacity as head of an

• rganized medical staff and whose duties include (1)

training and supervision of medical staff (both physician and non-physician); (2) drafting and implementation of appropriate policies and procedures; and/or (3) assuring the facility's compliance with federal, state and local laws. Medical director services do not include employment related practices.

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Cyber Liability Coverage

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Types of Risks

 lost laptops;  theft of hardware or data;  improper disposal of medical records;  hacking or virus attacks;  rogue employees;  cyber extortion; or  cyber terrorism.

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A Growing Problem

 Panda labs, an antivirus software vendor, reported

that there were 60,000 strains of malware in existence in 2010.

 In 2010, FBI’s International Crime Complaint Center

(IC3) received the second-highest number of identity theft complaints since its inception. IC3 also reached a major milestone this year when it received its two millionth complaint. On average, IC3 receives and processes 25,000 complaints per month.

 Texas is third in cybercrime complaints (7.3%) in the

U.S.

 Texas is fourth for cybercrime perpetrators (6.9%) in

the U.S.

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Laws

Federal

 HIPAA (1996)  HIPAA Privacy Rule (2002)  HIPAA Security Rule (2003)  HITECH additions to HIPAA (2009)  Non-HIPAA: Federal Confidentiality Law 42 CFR

Part 2, CMS, JCAHO, CLIA, FERPA, ERISA, FTC Red Flags Rule… State

 Texas new privacy law HB300 (2012)  Texas Medical Practice Act (Occupations Code)  Various other statutes

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Limits

Cyber liability policy limits are $50,000 per claim subject to a $50,000 aggregate per policy period and there is no deductible. If the policy is on a group policy form, the policy aggregate for all policyholders is $250,000. Higher limits of $1 million are available at a discounted cost, should a policyholder request them. Payment directly to physician for system damage Payments to others if claim against physician for privacy breach

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Coverages

 Network security and privacy insurance  Regulatory fines and penalties insurance  Privacy breach response costs, patient notification expenses,

and patient support and credit

 Monitoring costs insurance  Network asset protection  Multimedia insurance  Cyber extortion  Cyber terrorism

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TMLT EPLI Policy – eff. 2-1-13

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Limits of Liabilty

ITEM 3. LIMIT OF LIABILITY (inclusive of Defense Costs): (a) USD 50,000 Maximum Limit of Liability for each Claim (b) USD 50,000 Punitive, exemplary and multiple damages Limit of Liability. (c) USD 50,000 Maximum aggregate Limit of Liability for all Claims. (d) USD NIL Defense-Only Limit of Liability. $5000 SIR per claim

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Definition of Loss



Judgments or settlements



Defense costs in excess of SIR



Punitive damages Does not include



Fines, administrative penalties or taxes



Amounts owed under employment contracts



Severance pay



Disability, SS, WC, medical, insurance, retirement or pension benefits



Cost to modify premises for disabled person



Any relief imposed in criminal lawsuit

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MEDEFENSE

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Medefense



Limits of Liability $100,000 per disciplinary proceeding



Pays Legal and Tax Expense as well as Fines and/or Penalties



If use panel counsel, no deductible ($1000) and payment directly to the attorney, otherwise reimbursement



Insurer does not monitor the progress

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Disciplinary Proceeding:

1.

Review action by hospital, HMO, PPO or managed care organization

2.

Proceeding by state medical licensing authority

3.

Certain OIG claims

4.

Proceeding by state or federal agency alleging medical services in violation of guidelines for appropriate utilization of services

• 5. Medicare/Medicaid billing issues

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6.

Violations of the Emergency Medical Treatment and Active Labor Act (EMTALA)

7.

Violations of HIPAA

8.

Violations of Stark Law