GOALS
1. Introduce MMTP practitioners to the elements of a Risk Management Program and its application to a methadone treatment program.
2. Promote an appreciation of the need to make MMTP’s more attractive to the Insurance Market through the use of Risk Management tools.
WHEN ADVERSE EVENTS OCCUR
Human Cost
Threat To Corporate Reputation
Loss Of Consumer Confidence
Poor Employee Morale
Time & Expense Of Defending A Claim
Increase In Insurance Premiums
Medical Staff
Credentialing
Business Arrangements
Peer Review/Quality Improvement Activities
Scope Of Risk Management cont…
Financial
Director’s Liability
Office’s Liability
Corporate Liability
Scope Of Risk Management cont…
RISK IDENTIFICATION & ANALYSIS
Incident/Occurrence Reports
Patient Complaints
Medication Incident Reports
Audits
Generic Outcome Screens
Common Risk Identifiers
Risk Identification & Analysis cont…
The Grape Vine/Word Of Mouth
Pharmacy and Therapeutic Reports
Medical Credentialing/Recredentialing
Historical Claims Data
Accreditation & Regulatory Agencies
SETTING PRIORITIES
Facts To Consider
Frequency Of Occurrence
Severity Of Occurrence
Annual Dollar Amount Of Loss
External Economic Factors
Cost Of Defending Potential Claims
Loss Of Reputation In The Community
Setting Priorities cont.
Risk Prevention cont…
Communication cont…
It is a process that must adjust to each patient and includes an exchange of information.
Risk Prevention cont…
Communication cont…
It is the responsibility of the provider to be certain a patient gives consent before care is given.
Risk Prevention cont…
Communication cont…
Disclosure: The new mantra from regulatory agencies and the law.
Risk Prevention cont…
Communication cont…
Disclosure: Is it really different from other patient interactions?
? ? ? ?
Risk Prevention cont…
Compliance
HIPPA 1996: Fraud is the knowing and willful execution or attempt to execute a scheme to defraud a health care benefit program to obtain by means of false or fraudulent representations or promises, any money or other property owned by a health care benefit program.
Risk Prevention cont…
Compliance cont…
False claims and fraudulent billing
Bribes, kickbacks, excessive or unreasonable discounts and rebates, and profit-sharing agreements
Payment to induce referrals
Medical neglect of a patient
Enforcement Laws
Risk Prevention cont…
1977 Medicare-Medicare Anti-Fraud and Abuse Amendment to the Social Security Act, including the Anti-Kickback Provisions
The Criminal False Claims Act
The Civil False Claims Act
The Civil Monetary Penalties Act
Program exclusion of the Social Security Act
Risk Prevention cont…
Enforcement Laws
Federal Sentencing Guidelines: Provide for more lenient punishment for organizations that adopt effective programs for detecting and preventing criminal conduct.
RISK AVOIDANCE
1. Avoidance is a risk treatment strategy. If a given risk is too serious for the provider to manage or transfer, the procedure that gives rise to it may need to be avoided all together.
Risk Avoidance cont…
2. Minimization tries to reduce the severity of an event that has already occurred. For example, prompt incident investigation, duplicate records.
Risk Avoidance cont…
3. Transfer is shifting the risk of financial loss to another entity, either through contract or insurance.
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