Outcomes of medical malpractice claims in assisted reproductive technology over a 10-year period from a single carrier.

OBJECTIVE: Medical malpractice claims vary by specialty. Contributory factors to malpractice in reproductive endocrinology and infertility (REI) are not well defined. We sought to determine claims' frequency, basis of claims, and outcomes of settled claims in REI. DESIGN: This is a retrospective, descriptive review of 10 years of claims. SETTING: The setting is private practices. MATERIALS AND METHODS: Claims were monitored within one malpractice carrier between 2006 and 2015 covering 10 practices and 184,015 IVF cycles. Total claims, basis of claims, and indemnity paid were evaluated. RESULTS: There were 176 incidents resulting in 30 settled claims with indemnity payments in 21. Categories of claims settled included misdiagnosis (N = 4), lack of informed consent (N = 5), embryology errors (N = 8), and surgical complications (N = 4). Total and average awards were $15,062,000 and $717,238, respectively. Misdiagnosis and lack of informed consent had highest total award amount at $11,583,000 accounting for 76% of award dollars. The two highest awards were $4.5 million and $3.0 million for cancer and genetic misdiagnosis, respectively. Excluding these two awards, payments totaled $7,562,000, ranged from $6000 to $900,000 and averaged $170,363. Errors in handling of embryos were highest in frequency accounting for 38% of claims paid for a total of $1,593,000 with average payment of $199,188. Settlements for surgical complications totaled $1,855,000 and averaged $463,750 per claim. CONCLUSIONS: Misdiagnosis and lack of informed consent are the highest award categories. Embryology lab errors are the most frequent causes of claims with the lowest award per settlement. The average cost for claims settled is relatively high compared to settlements in other specialties.

Operator-related aspects in endodontic malpractice claims in Finland.

OBJECTIVE: We analyzed operator-related differences in endodontic malpractice claims in Finland. MATERIALS AND METHODS: Data comprised the endodontic malpractice claims handled at the Patient Insurance Centre (PIC) in 2002-2006 and 2011-2013. Two dental advisors at the PIC scrutinized the original documents of the cases (n = 1271). The case-related information included patient's age and gender, type of tooth, presence of radiographs, and methods of instrumentation and apex location. As injuries, we recorded broken instrument, perforation, injuries due to root canal irrigants/medicaments, and miscellaneous injuries. We categorized the injuries according to the PIC decisions as avoidable, unavoidable, or no injury. Operator-related information included dentist's age, gender, specialization, and service sector. We assessed level of patient documentation as adequate, moderate, or poor. Chi-squared tests, t-tests, and logistic regression modelling served in statistical analyses. RESULTS: Patients' mean age was 44.7 (range 8-85) years, and 71% were women. The private sector constituted 54% of claim cases. Younger patients, female dentists, and general practitioners predominated in the public sector. We found no sector differences in patients' gender, dentists' age, or type of injured tooth. PIC advisors confirmed no injury in 24% of claim cases; the advisors considered 65% of injury cases (n = 970) as avoidable and 35% as unavoidable. We found no operator-related differences in these figures. Working methods differed by operator's age and gender. Adequate patient documentation predominated in the public sector and among female, younger, or specialized dentists. CONCLUSIONS: Operator-related factors had no impact on endodontic malpractice claims.

Claims Procedure for Plans Providing Disability Benefits. Final rule.

This document contains a final regulation revising the claims procedure regulations under the Employee Retirement Income Security Act of 1974 (ERISA) for employee benefit plans providing disability benefits. The final rule revises and strengthens the current rules primarily by adopting certain procedural protections and safeguards for disability benefit claims that are currently applicable to claims for group health benefits pursuant to the Affordable Care Act. This rule affects plan administrators and participants and beneficiaries of plans providing disability benefits, and others who assist in the provision of these benefits, such as third-party benefits administrators and other service providers.

The False Claims Act: Increases in Investigations, Violations, and Penalties.

The False Claims Act is a tool used by the government, its contractors, and even employees of healthcare providers to recover overpayments and other improper reimbursements given to physicians for healthcare services provided to Medicare and other federal health program beneficiaries. In recent years, we have seen an increase in the number of False Claims Act cases filed against unsuspecting healthcare providers and practices. These cases have resulted in billions of dollars being paid back to the federal government. Knowing and understanding the requirements of the False Claims Act and implementing best practices and strategies to avoid violating any of these provisions will help practices to ensure that they do not become subject to the massive penalties imposed on violators.

Submission of evidence in disability claims. Final rule.

We are clarifying our regulations to require you to inform us about or submit all evidence known to you that relates to your disability claim, subject to two exceptions for certain privileged communications. This requirement includes the duty to submit all evidence that relates to your disability claim received from any source in its entirety, unless you previously submitted the same evidence to us or we instruct you otherwise. We are also requiring your representative to help you obtain the information or evidence that we require you to submit under our regulations. These modifications to our regulations will better describe your duty to submit all evidence that relates to your disability claim and enable us to have more complete case records on which to make more accurate disability determinations and decisions.

Medicaid Program; Mechanized Claims Processing and Information Retrieval Systems (90/10). Final rule.

This final rule will extend enhanced funding for Medicaid eligibility systems as part of a state's mechanized claims processing system, and will update conditions and standards for such systems, including adding to and updating current Medicaid Management Information Systems (MMIS) conditions and standards. These changes will allow states to improve customer service and support the dynamic nature of Medicaid eligibility, enrollment, and delivery systems.

8 Critical steps for 2-midnight compliance.

Organizations can prepare for compliance with the two-midnight rule by: Embedding questions from the optional certification form within electronic orders or using the manual form Educating their physicians Empowering their utilization review team

The seven elements of a payable claim.

Healthcare providers are obligated to comply with a wide range of statutory and regulatory requirements associated with the provision, documentation, coding, and billing of a medical claim. It is important to keep in mind that the viewpoint of an outside auditor is not going to be the same as that of the treating physician. For instance, when documenting medical services, the information viewed as most significant (and therefore recorded) by a treating physician may be very different from the information an outside auditor hopes to glean from a patient's record. As a result, a significant disconnect between the parties may occur. To avoid this, it is essential that a treating physician or other healthcare provider diligently work to help ensure that claims submitted to Medicare, Medicaid, or a private payer fully comply with all applicable coverage and payment requirements. We have developed a checklist that we refer to as "The Seven Elements of a Payable Claim" to assist providers in this effort.

2012 financial outlook: physicians and podiatrists.

Although the nationally unadjusted average Medicare allowable rates have not increased or decreased significantly, the new codes, the new coding regulations, the NCCI edits, and the Medicare contractors' local coverage determinations (LCDs) will greatly impact physicians' and podiatrists' revenue in 2012. Therefore, every wound care physician and podiatrist should take the time to update their charge sheets and their data entry systems with correct codes, units, and appropriate charges (that account for all the resources needed to perform each service or procedure). They should carefully read the LCDs that are pertinent to the work they perform. If the LCDs contain language that is unclear or incorrect, physicians and podiatrists should contact the Medicare contractor medical director and request a revision through the LCD Reconsideration Process. Medicare has stabilized the MPFS allowable rates for 2012-now physicians and podiatrists must do their part to implement the new coding, payment, and coverage regulations. To be sure that the entire revenue process is working properly, physicians and podiatrists should conduct quarterly, if not monthly, audits of their revenue cycle. Healthcare providers will maintain a healthy revenue cycle by conducting internal audits before outside auditors conduct audits that result in repayments that could have been prevented.

Simplification at last?

The HIPAA transaction standards-meant to streamline financial and administrative transactions--have instead devolved into a kind of free-for-all. Now the first operating rules are in hand to standardize use of the standards and gain the efficiencies originally intended.

Bad medicine: prescription drugs, preemption, and the potential for a no-fault fix.

For decades, federal regulation of pharmaceutical drugs and medical devices has worked hand in hand with state tort claims to protect the health and safety of the American public. Now, a new trend toward preemption endangers this scheme. In recent years, the Supreme Court has given increasing deference to agency assertions about their preemptive authority and has found preemption in an increasing number of cases. In the process, the Supreme Court has preempted claims for medical device injuries and left claims for pharmaceutical harms in a precarious position. The elimination of common law claims for drug and device harms will leave holes in the FDA's regulatory scheme, endangering the health and safety of Americans. It will also prevent ordinary Americans from seeking compensation for their injuries--even those injuries caused by manufacturer malfeasance. This Article proposes that Congress create a no-fault compensation scheme for drugs and medical devices to close these gaps. Such a scheme could be both practical and politically possible, satisfying manufacturers, tort reformers, patients, and plaintiffs' lawyers alike.

Implementing US-style anti-fraud laws in the Australian pharmaceutical and health care industries.

This article critically analyses the prospects for introducing United States anti-fraud (or anti-false claims) laws in the Australian health care setting. Australian governments spend billions of dollars each year on medicines and health care. A recent report estimates that the money lost to corporate fraud in Australia is growing at an annual rate of 7%, but that only a third of the losses are currently being detected. In the US, qui tam provisions - the component of anti-fraud or anti-false claims laws involving payments to whistleblowers - have been particularly successful in providing critical evidence allowing public prosecutors to recover damages for fraud and false claims made by corporations in relation to federal and state health care programs. The US continues to strengthen such anti-fraud measures and to successfully apply them to a widening range of areas involving large public investment. Australia still suffers from the absence of any comprehensive scheme that not only allows treble damages recovery for fraud on the public purse, but crucially supports such actions by providing financial encouragement for whistleblowing corporate insiders to expose evidence of fraud. Potential areas of application could include direct and indirect government expenditure on health care service provision, pharmaceuticals, medical devices, defence, carbon emissions compensation and tobacco-related illness. The creation in Australia of an equivalent to US anti-false claims legislation should be a policy priority, particularly in a period of financial stringency.