Post on 14-Jul-2015
transcript
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