RISK MANAGEMENT IN THE TREATMENT OF OPIOID DEPENDENCE

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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
MMTPs 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
Directors Liability
Offices 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
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.
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Risk Avoidance cont
2. 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
3. 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