Tag Archives: doctors

5 Reasons Doctors Are ‘Non-Standard’

Non-standard physicians and surgeons are practicing doctors who have had claims frequency or severity issues or board actions or have been previously or are currently on probation. It can often be difficult for non-standard physicians to find affordable malpractice insurance coverage because they are considered a higher risk by insurance companies. Typically, a doctor remains in the non-standard market for about five years, provided once they enter the non-standard market they have kept themselves clean. In this post, we examine the top five reasons doctors become non-standard physicians.

#1 Claims – The common reasons for claims filed against physicians include: poor communication, poor bedside manner, erroneous documentation and failure, delay or change in diagnosis. To reduce the likelihood of lawsuits and claims, physicians might take just a few minutes of extra time to answer all questions and address all concerns. Patients and their families will walk away feeling as though they had all the information, even if a bad outcome occurred. They will be much less likely to seek the counsel of an attorney. Click here to read our blog post Top 5 Reasons Doctors Get Sued.

#2 Lack of informed consent – Informed consent should occur with every patient encounter. Patients must be informed on the details of their options, especially when care involves an invasive or new, cutting-edge procedure. Top breaches in informed consent that lead a doctor to the non-standard market include the use of non-FDA approved medications, and new or innovative procedures. Physicians should engage with a risk management consultant to learn best practices and get risk management advice specific to a particular practice specialty, especially those that are considered high-risk.

#3 Substance abuse issues – While physicians are about as likely to abuse alcohol or illegal drugs as any member of the general public, they are more likely to misuse prescription drugs. The motivation for this often initially includes the relief of stress or pain or to stay alert when suffering from sleep deprivation. Physicians often work strange hours and long shifts, especially in the ER. The cycle often begins by using medication to stay awake and alert to manage the stress and the hours. These stresses combined with easy access to medications can lead to substance abuse issues.

#4 High-risk practice profile – Physicians in a practice with higher claim ratios automatically fall into the category of “high risk.” Examples of high-risk specialties include: bariatric surgery, OB/GYN, neurosurgery, plastic surgery and pain management. These specialties are either composed of high-risk and invasive procedures such as in the case of surgeons or they are prescribing medications that are new or dangerous, such as with weight-loss or pain-management clinics. Physicians in these practices will most likely have to remain in the non-standard market throughout their entire careers.

#5 Poor record keeping – Following a bad outcome or an adverse event, the first thing that the patient’s attorney will request is a copy of medical records. These will be scrutinized. Any incorrect or conflicting information contained within the medical record will prove problematic for the physician’s case. Accurate and thorough record keeping proves especially challenging for older physicians, who may have been away from practice for some time and re-enter wanting to pick up where they left off. Or perhaps they are just resistant to change. Medical clinics are now using electronic medical records (EMR), which provides a more streamlined and accurate system of record keeping; they even have informed consent forms built right in. From a risk management perspective, EMR is highly encouraged.

Bottom Line – Physicians should consult a clinical risk management expert for help in developing strategies to decrease the risk of becoming a non-standard physician. Thorough protocols covering documentation, informed consent and communication will all prove invaluable in risk reduction. It’s also important that doctors are honest about their personal bandwidth when it comes to patient load capacity, stamina for extended work hours, overall physical and emotional health and stresses that may be coming from personal circumstances. These factors are important to consider and if not tended to can lead to events that have a long and lasting impact on a doctor’s ability to practice medicine.

Why Doctors Don’t Trust Insurers

Having health insurance and dependable healthcare is one of the biggest concerns for people all over the world, but, unfortunately, there are many doctors who simply don’t trust the health insurance their patients use. No matter if you currently have health insurance, knowing what your doctor feels about your coverage can give you a deeper insight into just how well (or poorly) insured you truly are.

One of the main reasons physicians don’t trust health insurance providers is because they feel insurance companies prevent them from offering patients the absolute best care. It’s understandable to be upset at the idea of not being able to perform your job to the best of your abilities.

Insurance providers that are considered the most trustworthy include Blue Cross Blue Shield and Cigna, while those deemed the least trustworthy are UnitedHealthcare and Humana. These results stem from a 2015 survey conducted by the ReviveHealth Payor Trust Index, with responses from more than 600 specialists and primary care physicians. One thing to note is that Blue Cross Blue Shield earned a combined trust index rating of about 60 out of 100, which was the highest score but which also leaves an abundance of room for improvement.

The Future of American Health Insurance

The two most important factors physicians cited as influencing their opinions about how health plans help or hurt the quality of care they deliver were the level of coverage and number of claim denials.

Physicians might also soon have to contend with new medical insurance companies made up of two or more of the most difficult companies to deal with, such as through the proposed merger of Anthem and Humana. If the deal goes through, physicians might find health insurance companies to be downright insufferable.

Additional Reasons

Besides having their hands tied, doctors provided the ReviveHealth Payor Trust with several more reasons they distrust health insurance companies. Physicians also don’t believe insurance providers do their best to honor commitments made to policyholders. Nor do they believe that companies advertise themselves accurately or honestly. Respondents to the survey also said insurance providers take advantage of doctors.

If even doctors don’t trust insurance companies, where does that leave their patients? Not only do doctors have a better idea than their patients about how the human body works, doctors also have a better idea about how the health insurance industry works. If you’re considering health insurance plans, or if you’re thinking about switching insurance providers, ask your doctor for recommendations.

Urgency of Rising Medicare Fraud

Ho-hum: The FBI arrested 46 doctors and nurses…largest Medicare fraud bust ever.

That is from a headline in a recent CNN story. Seems the thieving doctors and nurses got away with $712 million before getting busted.

Per the story, “In total, 243 people were arrested in 17 cities for allegedly billing Medicare for $712 million worth of patient care that was never given or unnecessary.”

Note the word “unnecessary.” If there are doctors and nurses doing this to Medicare patients, they are defrauding self-insured benefit plan patients, too.

This has been getting worse and worse every year for 20 or so years. I say “ho-hum” at the beginning of this post because almost no one in the private sector takes stopping this kind of thing seriously. There is a lot of talk and little action.

I urge readers to start taking steps to stop this mess.

Promoting Peace of Mind in Work Comp

An employee’s peace of mind is equal in concern with the physical injury when it comes to a worker’s comp claim. An upset employee can lose motivation, incur a bad attitude and rationalize the over-use or abuse of WC benefits. I am adamant that employee satisfaction is as key a factor in WC claim outcomes as it is in overall employee productivity and job performance.

It is not the adjuster’s primary role to manage an employee’s peace of mind at the start of a new report. While we expect good “bedside manner” from an adjuster, she must reserve a defensive position and be a “bad-cop” if necessary. An astute employer sees the opportunity in meeting an employee’s concerns at the time of an injury. It is like adding another critical brick to strengthen the foundation of employee satisfaction.

The immediate task can be simple. A little bit of confident communication goes a long way. Step one is to put yourself in the injured employee’s shoes and imagine being faced with an inability to work. It is not a comfortable feeling.

Quick Tip: Prepare a “Top-10” Information Sheet for Quick Use

Concept: Include a quick-reading “Frequently Asked Questions” checklist as part of an overall information packet for new WC claimants.

Suggested Top 10 and Recommended Answers:

1) Which doctor do I use? – Identify the preferred list, contracted clinic or emergency facility. Explain degrees of employee choice if any does exist in your jurisdiction.

2) What if I can’t do my job? – “If the doctor determines you cannot perform your job, we will try to match you with a temporary alternate assignment. If there is no ability for you to work, your wages will be paid as a WC benefit.”

3) How much will I be paid? – Provide the statutory calculation formula for the comp rate and specify that the employee’s specific rate will be determined by the claims adjuster within 48-72 hours.

4) When do I start getting checks? – Explain the jurisdictional waiting period.

5) How do medical bills get paid? – “All bills will be paid directly to the doctors/providers. You do not pay any bills for accepted and covered treatment.”

6) Do I need an attorney? – “We will help facilitate your benefits. An attorney is not necessary unless you face a disputed issue and want it to be heard by a judge. However, it is your option and right to consult an attorney at any time.”

7) What do I do next? – Explain any other internal steps and forms; explain that an adjuster will make contact and go over additional information. If you have a designated adjuster, provide a name and contact info.

8) What about my health benefits / 401k contributions, etc? – Explain your policies and the jurisdictional requirements that continue benefits during a WC claim

9) Will I lose my job or be fired? – Explain that filing a WC claim is not a basis for termination but also reserve the right for progressive discipline because of safety violations, attendance, job abandonment, fraud and any internal policies that might relate to WC situations.

10) What if I have other questions? – Provide a designated internal WC contact with an open-door policy.

Do You Know Who Your Best Doctors Are?

In workers’ compensation, the medical provider network philosophy has been in place for years. Most networks were developed using the logic that all doctors are essentially the same. Rather than evaluate performance, the focus was on obtaining discounts on bills, thereby saving money.

Physician selection by adjusters and others has frequently been based on subjective criteria. Those include familiarity, repetition, proximity and sometimes just assumption or habit. Often the criteria is something as flimsy as, “We always use this doctor,” or “The staff returns my calls.” The question is, which doctors really are best, and why?

The first assumption that must be debunked is that discounts save money. Doctors are smart—no argument there. So to make up the lost revenue for discounted bills, they increase the number of visits or services to the injured worker or extend the duration of claims by prolonging treatment. To uncover these behaviors, examine the data.

Amazingly, even doctors do not always make the best choices about other doctors. They may recommend doctors they know socially, professionally or by informal reputation, but they may not know how the doctors actually practice. They may not know a physician upcodes bills, dispenses medications or over-prescribes Schedule II drugs. The data will reveal that information.

Doctors may be unaware they are adding to claim complexity by referring to certain specialists. Again, familiarity and habit are often the drivers. On the other hand, duplicity among providers is fraudulent behavior, and it can be uncovered by examining the data.

Analysis of data can expose clustering of poorly performing, abusive or fraudulent providers referring to one another. The analysis may also divulge patterns of some providers associated with certain plaintiff attorneys.

Treating doctors influence claims and their outcomes in other ways. Management indicators unique to workers’ compensation such as return to work, indemnity costs and disability ratings can be analyzed in the data to spotlight both good and poor medical performance. These outcome indicators are either directed by or influenced by the physician, and they can be uncovered through data analysis.

Claims adjusters and other non-medical persons simply cannot evaluate the clinical capability of medical providers, especially doctors. Performance analysis must take place at a higher level. Evaluations for specific ICD-9 diagnoses and clinical procedures such as surgery must be made. Frequency, timing and outcome can be examined in the data in context with diagnoses and procedural codes, thereby disclosing the excellence or incompetency of physicians.

Negative clinical outcomes that can be analyzed include hospital readmissions, repeated surgery or infection. Physicians associated with negative medical outcomes should be avoided.

When analyzing clinical indicators for performance, care should be taken to compare only similar conditions and procedures. Without such discrimination, the results are dubious. Specificity is critical.

When using data analysis to find the best doctors and other medical providers, fairness is also important. Provider performance should be compared only with similar specialty providers for similar diagnoses and procedures. Results will not be accurate or reliable if performance analysis is not apples-to-apples.

Medical providers may question data analysis to evaluate performance, claiming they treat the more difficult cases. The data can be analyzed to determine diagnostic severity, as well. Diagnostic codes in claims can be measured and scored, thereby disclosing medical severity.

Now is the time to step up to a much more dignified and sophisticated approach to selecting medical providers. Decisions about treating physicians must be based on fact, not assumption or habit. Fortunately, the data can be analyzed to locate the best-in-class and expose the others.