Monday, August 12, 2013

REPORTING OCCURRENCES TO THE PLAN

As  part  of  the  CarePlus  Risk  Management  Program  physicians  and  other  health  care  providers  are expected to report any occurrences and/or adverse incidents of a plan member, whether it happens in their office or in any other facility.

An occurrence is defined as any unforeseen complication or unusual event in which a plan member is involved.  Examples of occurrences are:

** Complication of drug, treatment, or service prescribed
** Dissatisfaction angrily expressed with threats
** Delay in care, diagnosis or referral
** Breach of confidentiality
** Receipt of a Notice of Intent to initiate litigation against a contracted physician or facility

An adverse incident is defined as an event over which health care personnel could exercise control and which is associated in whole, or in part with medical intervention rather than the condition for which such intervention occurred and which results in one of the following:

** Unexpected death of a patient
** Brain or spinal damage
** Performance of surgical procedure on the wrong patient
** Performance of wrong site surgical procedure
** Performance of a wrong site surgical procedure
** Performance of a surgical procedure that is medically unnecessary or otherwise unrelated to the patient’s diagnosis or medical condition
** Surgical repair of damage resulting to a patient from a planned procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process
** Performance  of  procedure  to  remove  unplanned  foreign  objects  remaining  from  a  surgical procedure
** Never  Events – as per CMS guidelines

In the state of Florida, occurrences and adverse events must be reported to the CarePlus Risk Manager within  3  calendar  days,  F.S.  59A-12.012.  The  information  submitted  to  CarePlus  is  used  for  state mandated risk management review.
 
Independent physicians or private practice physicians and their health plan medical director.

** Telephonically between the independent physician and the health plan medical director.

** Telephonically between the office staff and the health plan risk manager or provider representative.

** In writing by completing a Member Occurrence Report, filled out by the independent physician or office staff.  For your convenience we have included a copy of the Member Occurrence Report under the “Forms” section of this Manual. The report should be mailed to the Risk Manager, Medical Director, or the designated Provider Service Executive.  Facsimiles should be avoided because of lack of confidentiality.

Group physicians and their staffs should use the following methods:

** Telephonically between the group medical director/group leader and the health plan medical director.

(The  group  physician,  who  becomes  aware  of  an  occurrence,  should  report  the  occurrence  to  the group medical director/group physician leader.)

** Telephonically between the office staff and the health plan risk manager or provider representative.

** In writing by completing a Member Occurrence Report filled out by the group medical director/group physician leader or office staff.  The report should by mailed to the risk manager, medical director, or the  designated  provider  representative.  Facsimiles  should  be  avoided  because  of  lack  of confidentiality.

Note: Allied health care professionals  should report to their supervising physician.  All other health care providers should report as independent physicians.

The information submitted to the health plan is used to investigate potential quality issues and for risk management  review.  All  information  reported  to  the  health  plan  will  remain  strictly  confidential  in accordance with the policy and procedure on confidentiality.

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