risk management in the treatment of opioid dependence

RISK MANAGEMENT IN THE TREATMENT OF OPIOID

DEPENDENCE

Presented by:

Barbara A. M. Maloney, Esq.

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

Patient Care

Clinical

Procedural

SCOPE OF RISK MANAGEMENT

Medical Staff

Credentialing

Business Arrangements

Peer Review/Quality Improvement Activities

Scope Of Risk Management cont…

Employee

Injury

Discrimination/Harassment

Workers’ Compensation


Property


Financial

Director’s Liability

Office’s Liability

Corporate Liability


Regulatory Compliance


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

Strategic Planning

Education - Competencies

Contracts Review

Communication

Risk Prevention cont…


Communication cont…

Consent to treatment is not a piece of paper



It is a process that must adjust to each patient and includes an exchange of information.



It is the responsibility of the provider to be certain a patient gives consent before care is given.



Disclosure: The new mantra from regulatory agencies and the law.



Disclosure: Is it really different from other patient interactions?

? ? ? ?


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.


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


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


Enforcement Laws

Federal Sentencing Guidelines: Provide for more lenient punishment for organizations that adopt effective programs for detecting and preventing criminal conduct.

Preventive Maintenance

Claims Loss Analysis


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.

CLAIMS MANAGEMENT

Investigate

Set Up Files

Mandatory Reporting

Secure Equipment & Records

Set Up Reserves

risk management in the treatment of opioid dependence

Documents

risk management program

use of risk management

health care benefit

methadone treatment

patient interactions

fraudulent billingbribes

insurance market

criminal condu