CAP’s reserve philosophy is to reserve each claim for the ultimate amount they expect to pay on an individual claim. Initial loss reserves are typically posted on average seven months from the first report of loss; this is due in part to the generally slow development of medical malpractice claims as well as the completion of their preliminary investigation. CAP’s investigation is template in nature, addressing several crucial factors, outlined below. • Insured Interview: determine whether there was a breach of the standard of care. • Insured’s Medical Records: is the insured record’s well documented with respects to the claimant’s medical condition, diagnosis, treatment and whether alternative medical treatment plans were offered. • Medical Consent: was proper medical consent obtain …show more content…
o Did the ME find there was a deviation from standard of care and it play a role in the claimant’s injuries. • Does the insured make an effective witness on their on behalf. Once the investigation is complete, all claims regardless of value are referred to their Claim Review Committee (Committee) for evaluation and further work up. The Committee consists of seven physicians, defense counsel, and a representative CAP’s claim executive team and the handling claim specialist. In addition to the previous mention parties, the defending insured physician is present during the committee review to provide additional incite to the loss. The loss is presented to the Committee in detail, outlining all the claims, medical and litigation challenges. In addition, the insured physician will have an opportunity to present his case, while also being questioned by his peers as well as defense counsel. Thereafter, the Committee will make a determination whether it is a case to settle or defend and proceed
In the case of Michael T. Vandall, M.D., Plaintiff and Appellant v. Trinity Hospitals, a corporation, and Margaret C. Nordell, M.D., the issue is about retaliatory discharge. It deals with problems with Trinity Hospital in North Dakota, Dr. Margaret Nordell and Dr. Michael Vandall, both physicians working in the OB-GYN department.
Nursefinders argues that the causes of action based on respondent superior liability failed because Drummond was a special employee of Kaiser or acted outside the course and scope of her employment. they also asserted that no triable issues listed on Montague’s negligence claim and the lack of cable cause of action precluded a derivative loss of consortium claim.
Registered Nurse Pausits, a defendant out of the many involved with Parson’s case, has failed to provide Randy Parson with the correct prescription drug during his stay at Standish. The Plaintiff wanted to prove that she unsuccessfully administered medication to Randy Parsons and that a reasonable jury can conclude the fact Pausits was aware of the risks to Parsons. The court has reversed the grant of summary judgment to Nurse Pausits, because this case would rise to the level of deliberate indifference. Plaintiff Parsons revealed that Pausits perceived facts to infer substantial risk to Randy Parsons and drew the inference. She had to state she was aware, which she did, of a substantial risk. Evidence has shown that Nurse Pausits could have gotten Dilantian for Randy Parson if she viewed the situation as an emergency. Pausit’s case has discovered confirmation that she administered 100mg of Dilantin to Randy Parsons August 27, at 6:00 p.m. However, in Randy’s toxicology report, no Dilantin was shown in his body for 3 days before his death, which was August 28. Wellbutrin was shown in Randy’s body instead of Dilantin, which is a form of an anti-depressant that helps people suffering from seizures and can prevent causing a seizure. Displayed that Pausits signed Randy’s Medication Administration Record (MAR), when the prison log showed that Registered Nurse Alexander performed the medication August 27, raises a red flag as to who performed the medication and what prescription was given. The Plaintiff provided enough evidence towards Pausits in that she has unsuccessfully administered the medication to Randy and that Pausits was aware of a substantial risk to Randy Parsons. Because of this, a jury can place more significance on the t...
The Board received a complaint on 04/02/2014 regarding patient Gloria Kinder from Dena Andrews who has a POA for health care matters on the patient. The complaint was regarding Dr. Negron taking over care of the patient after her primary care doctor retired. The complainant states that the doctor would not refill her potassium, did not do follow up labs, and would not care for the patient.
Historically, case management came to fruition as an answer to the shift of cost-based reimbursements to prospective payment models, assisting hospitals in keeping costs low regardless of the quality of care. However, as health care reform became effective, case management has grown into a newer role in assisting in the delivery of patient-centered quality care. Typically, case managers must be self
Negligence cases necessitate that the standard of care required of an individual is the same conduct of a reasonably prudent person under the same or similar circumstances. However, a specialist within a profession may be held to a standard of care greater than that of a general practitioner. This also needs to be an objective standard.
In order for hospitals and other health care facilities to prevent the thousands of deaths and injuries that occur every year due to medical errors; health care systems were required to implement new record keeping technology. This technology has made patient information and treatment accessible to all who needed to see it. This is especially important when a patient has more than one attending physician and their care relies on each doctor knowing what the other one has done, serving as the prime communication tool between doctors. If organizations do not centralize their technology and essentially their patient databases, the potential for duplicate work or inefficient patient care can exponentially increase. These high tech medical records can help protect physicians and hospitals alike against any lawsuits that may be filed on behalf of their patients. By correctly and thoroughly documenting all symptoms, illnesses, treatments, medication dosages, and diagnosis’ the doctor and health care providers can effectively prove what actions were taken with the patient, communicate with third party billers, and even use the gathered information for teaching purposes. Keeping a precise record of a patient’s medical treatment makes a large difference in many aspects of health care; especially when a negligence tort or claim is filed against the hospital and/or a doctor.
There was inappropriate staffing in the Emergency Room which was a factor in the event. There was one registered nurse (RN) and one licensed practical nurse (LPN) on duty at the time of the incident. Additional staff was available and not called in. The Emergency Nurses Association holds the position there should be two registered nurses whose responsibility is to prov...
MACs are responsible for doing prepayment medical reviews on Medicare claims to make sure that the services are medically necessary and that the beneficiary has coverage. RACs use data mining activities to look for Medicare claims that may have been improperly overpaid or underpaid. ZPICs use medical review, evidence-based policies, and data analysis to identify possible abuse, fraud, and waste in Medicare claims. Agencies that focus on Medicaid claims include MICs(Medicaid Integrity Contractors), Medicaid RAC (Medicaid Recovery Audit Contractors), MFCU (Medicaid Fraud Control Unit), OMIGs (State Offices of Medicaid Inspector General), and PERM (Payment Error Rate Measurement). MICs work with the Medicaid Integrity Program of the Social Security Act to audit claims for over payment. They also provide education to providers on payment integrity. Medicaid RACs look for over-payment and underpayment of Medicaid claims and report possible instances of fraud and criminal activity. The MFCU is certified by the secretary of HHS and conduct state initiative to investigate and prosecute providers who have defrauded the Medicaid claims system. OMIGs work within each state to improve the state Medicaid program integrity and help coordinate fraud and abuse activities that span
It is unfortunate to say that medical malpractice is one of the leading causes of death in the United States. Medical malpractice is defined as negligence committed by a medical professional. Malpractice lawsuits have existed in the United States for more than 150 years, most of which were never pursued in court. Medical malpractice is interfering with patients’ rights as well as demanding high costs. However, medical malpractice can be overcome by managing the costs involved, and by regulating, enforcing and advocating patient rights.
However, there are certain issues that may result from unfilled gaps between the expected and the actual provided health care treatment, and these issues vary in severity. But unfortunately, there are many people as patients who may not be fully aware of their legal right to file clinical negligence claims that could have been valid and successful.
One important fact in this case is medication that the physician administered to the patient is not listed in the case study. All information must be documented, this helps to keep track in the event the patient gets a reaction this is significant information that must be recorded. Although this may be unimportant to the case this should still be listed. As this patient condition worsened he was diagnosed with osteomyelitis. As mentioned above knowing all medications being administered are important, when treatment first began the pharmacist in this case did exceptionally well keeping track of the medications being administered. Another important factor is that the pharmacist kept track of the care being provided to the patient because the pharmacist reviewed patient results he was able to make suggestions to the physician to check the patients creatinine levels. However the pharmacist in the case is the defendant. Although the pharmacist did well in reviewing the patient’s information during most of the treatment, he did fail to do a follow up check. The
Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur...
Health information opponents has question the delivery and handling of patients electronic health records by health care organization and workers. The laws and regulations that set the framework protecting a user’s health information has become a major factor in how information is used and disclosed. The ability to share a patient document using Electronic Health Records (EHRs) is a critical component in the United States effort to show transparency and quality of healthcare records while protecting patient privacy. In 1996, under President Clinton administration, the US “Department of Health and Human Services (DHHS)” established national standards for the safeguard of certain health information. As a result, the Health Insurance Portability and Accountability Act of 1996 or (HIPAA) was established. HIPAA security standards required healthcare providers to ensure confidentiality and integrity of individual health information. This also included insurance administration and insurance portability. According to Health Information Portability and Accountability Act (HIPAA), an organization must guarantee the integrity, confidentiality, and security of sensitive patient data (Heckle & Lutters, 2011).
There are several possible methods of addressing the healthcare concerns of today. I focused on three ways to address this issue. The first would it be to make electronic records universal. Secondly, focus on patient centered care. Lastly, start healthcare groups throughout the practice of medicine.