Risk Management

Link Between Risk Management and Successful Claim Defense

For decades risk managers have attempted to correlate lower claims activity in modern medical practice with higher risk management participation by physicians. One of the main problems presented when trying to draw reliable conclusions revolves around the extent to which lessons learned during risk management instruction are actually implemented within practice.

Many researchers report a lack of data surrounding practice patterns and protocols, especially in small solo and group physician practices when compared with larger institutional medical practice within hospitals and university settings.

In defense of more ophthalmic cases than any other carrier, OMIC is convinced of a strong connection between risk management and better claims experience. We’ve successfully closed many claims without payment knowing that good informed consent and practice protocols were the difference in defending our insured. In our 2011 Annual OMIC Members Report we identified significant improvement in our claims results, particularly a widening of the gap between OMIC and our competitors, that occurred at the same time OMIC’s policyholder participation rate in risk management increased by 25%.

A recent study by the Journal of the American Medical Association provides additional evidence that is similar to OMIC’s data. In the JAMA report, researchers compared claims resulting from inpatient and outpatient settings. Although claims are down for all patient encounters, the rate of decline within inpatient settings, where risk management activities and patient safety initiatives have become much more prevalent, was higher than the rate of decline within outpatient encounters. These results are especially surprising due to reasons for adverse events and claims:

Inpatient:

1. Surgical
2. Diagnostic
3. Treatment

Outpatient:

1. Diagnostic
2. Treatment
3. Surgical

One would expect that the higher percentage of surgical complications and resulting claims would be a drag on claim defense as compared to outpatient visits.

Because a larger percentage of ophthalmic patient encounters are being performed in outpatient settings (as compared with other medical specialties) we believe OMIC’s risk management program has been a key reason for our success (and our superior claim and financial results) as compared to multispecialty competitors without the same high level of loss prevention participation.

To read the full JAMA report go here: http://www.medicalnewstoday.com/releases/228193.php