Malpractice Insurance


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Malpractice Insurance

  1. 1. Module 27 Malpractice Insurance
  2. 2. Risks for APNs <ul><li>Errors and omissions that result in harm to patients </li></ul><ul><li>Noncompliance with an array of state and federal laws and regulations for reimbursement </li></ul>
  3. 3. Reducing Risks <ul><li>Maintain current clinical skills and knowledge </li></ul><ul><li>Document clear and supportable reasons for taking or not taking diagnostic and therapeutic actions </li></ul><ul><li>Document patient’s response to treatment </li></ul><ul><li>Maintain optimal professional and business relationships </li></ul>
  4. 4. History <ul><li>Nurses perceived they were protected against malpractice because most were employed by hospitals which as charitable institutions were exempt from malpractice </li></ul><ul><li>This misapprehension today too often directs the APN’s behavior </li></ul><ul><li>APNs need malpractice in this litigious society </li></ul>
  5. 5. Three Types of Exposure to Avoid <ul><li>Financial exposure from civil lawsuit </li></ul><ul><li>Licensure or certification actions from state or private associations </li></ul><ul><li>Civil or criminal sanctions and exclusion from participation in the federal health care programs due to fraud or abuse </li></ul>
  6. 6. Malpractice <ul><li>Type of professional negligence that </li></ul><ul><li>results when the practitioner fails (by act </li></ul><ul><li>or omission) to exercise due care and use </li></ul><ul><li>the degree of skill and learning, under that circumstances, that a reasonably prudent APN would use. Failure to follow </li></ul><ul><li>standard of care results in harm to patient or patient’s family. </li></ul>
  7. 7. Licensure/Certification Exposures <ul><li>Overpayment or false claim in the Medicare, Medicaid, or other federal healthcare program. </li></ul><ul><li>Substance abuse, fraud, unprofessional conduct, or failure to have written collaborative agreement with physician. </li></ul><ul><li>Failure to maintain essential professional credentials. </li></ul>
  8. 8. Noncompliance With Laws/Regulations <ul><li>Most severe penalty is exclusion from federal health care programs. </li></ul><ul><li>Excluded from reimbursement if convicted of a federal crime related to the delivery of an item or service paid for the federal health care program. </li></ul><ul><li>Program exclusion is a career ending event. </li></ul>
  9. 9. National Practitioner Data Bank <ul><li>Established 1986 by Congress </li></ul><ul><li>Maintained by DHHS; reports malpractice judgments and settlements </li></ul><ul><li>Healthcare Integrity and Protection Data Bank established in 1996 collects, reports </li></ul><ul><li>and discloses information regarding licensure and certification actions, program exclusions, criminal convictions, and other actions </li></ul>
  10. 10. Incidence of Claims <ul><li>2/3 of malpractice claims were made on behalf of RNs not APRNs </li></ul><ul><li>Of the APNs, CRNAs were the most frequently sued (65%); CNMs (20%);and NPs (13%). </li></ul><ul><li>NP cases related to diagnosis and treatment-related issues </li></ul>
  11. 11. What Affects Payment of Malpractice Claims in Each State? <ul><li>Statute of limitations </li></ul><ul><li>Caps on noneconomic damages </li></ul><ul><li>Attorney’s fees </li></ul><ul><li>Burden of proofs </li></ul><ul><li>Use of mandatory medical review panels </li></ul><ul><li>Use of arbitration to resolve issues </li></ul>
  12. 12. Who is Responsible? <ul><li>Respondeat Superior – ‘let the master respond’ If APN is in a true employment </li></ul><ul><li>relationship then employer is responsible </li></ul><ul><li>However APNs can be sued individually along with their employer </li></ul><ul><li>If APN does not have liability insurance then the APN is subject to the decisions of employer which may not be in the APN’s best interest </li></ul>
  13. 13. Bottom line . . . <ul><li>APN cannot afford to not have liability insurance of their own in order to have separate counsel that is not conflicted by the interests of the employer. </li></ul>
  14. 14. Collaborative Practice Settings <ul><li>In a true collaborative practice the APN is an independent practitioner and is not an employee. </li></ul>
  15. 15. Finding Malpractice Insurance <ul><li>Check professional association websites </li></ul><ul><li>Carriers generally provide legal counsel, pay defense legal fees, pay damages up </li></ul><ul><li>to limits of coverage </li></ul><ul><li>Find out number of claims that might be paid in a time frame </li></ul><ul><li>Are legal costs within the limits of liability or in addition to these limits? </li></ul>
  16. 16. Types of Coverage <ul><li>Occurrence: The policy that was in effect </li></ul><ul><li>at the time the adverse event occurred is the policy that applies for that claim </li></ul><ul><li>Claims made Coverage: Adverse events must occur and the claim must be made during the policy period. Must purchase extended future protection for today’s events. </li></ul>
  17. 17. Watch for . . . <ul><li>Insurance Carriers that: </li></ul><ul><li>Agree to consult with you </li></ul><ul><li>Will permit choice of counsel </li></ul><ul><li>Will not settle without written consent </li></ul><ul><li>Have experience in insurance </li></ul><ul><li>Are financially solvent </li></ul><ul><li>Rated by A.M. Best & Company </li></ul><ul><li>(A++ is the best rating) </li></ul>
  18. 18. Exclusions? <ul><li>Criminal Acts </li></ul><ul><li>Events against public policy </li></ul><ul><li>Liability coverage is a partnership – </li></ul><ul><li>truthfulness is essential </li></ul><ul><li>Notify insurer as soon as an adverse event occurs </li></ul>
  19. 19. Steps When a Suit is Filed <ul><li>Receive summons or complaint </li></ul><ul><li>Activate liability insurance </li></ul><ul><li>Anecdotal evidence collected </li></ul><ul><li>Risk manager notified </li></ul><ul><li>Keep discussion of case at a minimum </li></ul><ul><li>Do not pay any money without insurer’s consent </li></ul>
  20. 20. Insurer’s Response <ul><li>APN contacted by insurer’s claim representative </li></ul><ul><li>Determine conflicts of interest </li></ul><ul><li>APN interviewed by phone </li></ul><ul><li>Claim representative contacts employer </li></ul>
  21. 21. Legal Counsel <ul><li>APN advised of legal counsel </li></ul><ul><li>Legal counsel interviews APN </li></ul><ul><li>APN should contact insurer if not happy with legal counsel </li></ul><ul><li>Terms of defense given to APN </li></ul><ul><li>Discovery conducted to determine legal facts of the claim </li></ul><ul><li>Information used for settlement or trial </li></ul>
  22. 22. Settlement <ul><li>Degree of fault? </li></ul><ul><li>Social climate </li></ul><ul><li>Plaintiff socioeconomic factors </li></ul><ul><li>Local statutes </li></ul><ul><li>Previous jury verdicts </li></ul><ul><li>APNs ability to pay </li></ul><ul><li>Potential for excess of liability limits </li></ul><ul><li>Unpredictability of jury trial </li></ul><ul><li>Impractical for APN to testify in own defense </li></ul><ul><li>Medical records that do not support APN </li></ul>
  23. 23. Patient Has Burden of Proof <ul><li>Duty </li></ul><ul><li>Breach of Duty </li></ul><ul><li>Causal Connection </li></ul><ul><li>Damage </li></ul>
  24. 24. Managing Risks <ul><li>Foster positive relationships with patient and family </li></ul><ul><li>Improve delivery and documentation of care rendered </li></ul><ul><li>Understand/manage patient’s medical issues </li></ul><ul><li>Maintain professional competence by attending continuing education </li></ul><ul><li>Maintain professional relationships with colleagues </li></ul><ul><li>Manage business aspects well </li></ul>
  25. 25. To Sue or Not to Sue? <ul><li>Oftentimes depends on positive relationships. </li></ul>