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RISK MANAGEMENT IN THE TREATMENT OF OPIOID DEPENDENCE
Presented by: Barbara A. M. Maloney, Esq.
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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.
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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
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SCOPE OF RISK MANAGEMENT
Patient Care Clinical Procedural
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Scope Of Risk Management cont…
Medical Staff Credentialing Business Arrangements Peer Review/Quality Improvement Activities
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Scope Of Risk Management cont…
Employee Injury Discrimination/Harassment Workers’ Compensation
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Scope Of Risk Management cont…
Property
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Scope Of Risk Management cont…
Financial Director’s Liability Office’s Liability Corporate Liability
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Scope Of Risk Management cont…
Regulatory Compliance
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RISK IDENTIFICATION & ANALYSIS
Common Risk Identifiers Incident/Occurrence Reports Patient Complaints Medication Incident Reports Audits Generic Outcome Screens
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Risk Identification & Analysis cont…
Pharmacy and Therapeutic Reports Medical Credentialing/Recredentialing Historical Claims Data Accreditation & Regulatory Agencies The Grape Vine/Word Of Mouth
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SETTING PRIORITIES Facts To Consider Frequency Of Occurrence
Severity Of Occurrence Annual Dollar Amount Of Loss
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Setting Priorities cont.
External Economic Factors Cost Of Defending Potential Claims Loss Of Reputation In The Community
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RISK PREVENTION Strategic Planning Contracts Review
Education - Competencies
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Risk Prevention cont… Communication
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Risk Prevention cont… Communication cont… Consent to treatment is not a piece of paper
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Risk Prevention cont… Communication cont… It is a process that must adjust to each patient and includes an exchange of information.
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Risk Prevention cont… Communication cont… It is the responsibility of the provider to be certain a patient gives consent before care is given.
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Risk Prevention cont… Communication cont… Disclosure: The new mantra from regulatory agencies and the law.
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? ? ? ? Risk Prevention cont… Communication cont…
Disclosure: Is it really different from other patient interactions? ? ? ? ?
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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.
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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
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Risk Prevention cont… Enforcement Laws 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
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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.
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Risk Prevention cont… Preventive Maintenance Claims Loss Analysis
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RISK AVOIDANCE 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.
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Risk Avoidance cont… Minimization tries to reduce the severity of an event that has already occurred. For example, prompt incident investigation, duplicate records.
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Risk Avoidance cont… Transfer is shifting the risk of financial loss to another entity, either through contract or insurance.
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CLAIMS MANAGEMENT Investigate Secure Equipment & Records Set Up Files
Set Up Reserves Mandatory Reporting
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