Claims Management Best Practices: Thinking Beyond Resolution

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Claims Management Best Practices Thinking
Beyond Resolution

• Pamela L. Popp, MA, JD, DFASHRM, CPHRM,
  President, ASHRM
• Stanford University Medical Center

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Claims Management Best Practices

• Primary Goals
• Consistent application of insurance coverage
• Consistent claims reserving practices
• Implemented litigation management plans
• Aggressive management of defense counsel
• Proper use of mediation
• Decreased ALAE (allocated loss expense)

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Claims Management Best Practices

• Highest areas of liability payouts
• Failure to diagnose
• Medication errors
• Surgical errors
• Obstetrical errors

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Claims Management Best Practices
www.rmf.harvard.edu
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Claims Management Best Practices
Risk Management Foundation FORUM, February 2004
Vol. 23, No. 4.
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Claims Management Best Practices

• Claims are more than losses
• they are reflective of how the patient base
  perceives the facility and the care rendered.
• What does your claims history say about your
  program?

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Claims Management Best Practices

• Next level goals
• Evidence based risk management
• Completeness of trending information
• Strength of risk management database
• Data analysis options

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Claims Management Best Practices

• Advanced analysis levels
• Proactive
• Preventative
• Remedial
• Facilitative

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Claims Management Best Practices

• I. Proactive analysis
• New business assessments
• Return on investment analysis
• New liability theories
• What risks can we prevent?

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Claims Management Best Practices

• II. Preventative analysis
• Focused new employee orientation
• Resident simulation scenarios
• Comparative/industry benchmarking
• What should we be trying to prevent?

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Claims Management Best Practices
Risk Management Foundation FORUM, February 2004
Vol. 23, No. 4.
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Claims Management Best Practices
www.seifmedicalgraphics.com
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Claims Management Best Practices
www.seifmedicalgraphics.com
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www.seifmedicalgraphics.com
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Claims Management Best Practices

• III. Remedial analysis
• Prioritized criteria for reporting
• How will we know if they still happen?

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• The following matters should be reported from the
  facility under the Adverse Event procedures
• Apgar scores of less than 4 at 10 minutes
• Placental abruptions
• Uterine ruptures
• Neonates intubated within the first 20 minutes of
  life
• Amniotic fluid embolisms
• Shoulder dystocias
• Any unusual birth or nursery circumstance

Popp, P. OB Project, 2001
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Claims Management Best Practices
www.rmf.harvard.edu
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Claims Management Best Practices

• IV. Facilitative analysis
• Standardized investigations
• Standardized defenses
• Expert database
• Checklists
• What can we do to handle this situation, and
  others like it, as efficiently as possible?

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Claims Management Best Practices
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Claims Management Best Practices

• V. Remedial analysis
• Peer review/credentialing feedback
• Post mortem analysis
• Identified risk management issues
• What can we do to strengthen our defense in this
  situation and others like it?

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Claims Management Best Practices
Risk Management Foundation FORUM, February 2004
Vol. 23, No. 4.
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www.seifmedicalgraphics.com
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Thank you!

• ppopp_at_stanfordmed.org