Research shows that communication and early resolution programs, such as Stanford’s PEARL Program and COPIC Insurance Company’s 3Rs Program, have been successful in helping both patients and providers during the stressful time after an adverse event. Providers get support in communications with patients and their families, as well as assistance with medical/legal issues. Patients get help where they need it: medical, emotional, and financial. As result, these programs report a decrease in frequency of medical liability claims and litigation costs.
The CAP Cares Program
CAP Cares is an early intervention program designed to assist CAP members in response to adverse events arising from patient care. An adverse event can be either a known risk of medical care (a complication) or an injury caused by medical error.
In both instances, CAP’s experienced Risk Management team provides support to CAP members whose patients have experienced an unanticipated outcome. Their focus is to encourage early physician-patient communication, manage and maintain the treating relationship, and coach CAP members in their documentation of an adverse event.
Here is how CAP Cares helped one CAP member…
A Surprising Complication
A 33-year-old healthy married male with four children underwent a non-scalpel vasectomy early one evening in Dr. URO’s office. After getting home, the patient observed his left scrotum progressively getting larger and his pain intensifying. The concerned patient alerted Dr. URO about his symptoms and was instructed to go to the emergency room, where he was diagnosed with a large left scrotal hematoma and admitted to the hospital. During exploratory surgery the next morning, Dr. URO noted no active bleeding and removed a 200 ml blood clot. Later that evening, approximately 24 hours after his vasectomy, the patient was discharged in stable condition.
Dr. URO monitored the patient’s recovery over the next month. The hematoma and soft tissue swelling slowly improved with ice and elevation, and the patient’s pain was managed with oral medications. He did not experience any additional complications from surgery and was released from Dr. URO’s care.
Even though the medical record reflects that Dr. URO discussed the risks associated with a vasectomy, the patient was still surprised he suffered this known, but rare complication, and was extremely angry that he was hospitalized within hours of his vasectomy. As a business courtesy, Dr. URO assured the patient that he would not be billed for the vasectomy or the hematoma evacuation.
Five months later, the patient contacted Dr. URO’s office irate about the bills he received. Dr. URO’s staff billed the patient for the procedures, as they were not aware that Dr. URO advised the patient he would waive his fees. At the same time, the hospital was sending the patient to collections for $3,500 for non- payment of his portion of the $25,800 hospitalization bill. Over the telephone, the patient threatened legal action against Dr. URO for medical negligence. That’s when Dr. URO called the CAP Cares Hotline.
Patient Assistance Services
The CAP Cares specialist coached Dr. URO on how to handle the complaint and address his patient’s financial issues. Dr. URO apologized to the patient for the billing mishap and reassured him that the outstanding ledger balance would be waived. Dr. URO and the CAP Cares specialist worked with the patient to resolve the hospital billing issue through CAP’s Patient Assistance Services (PAS) program. As a result, the patient never filed a medical malpractice lawsuit against Dr. URO.
The PAS program allows for the consideration of payment of medical expenses, and associated costs, related to a medical error or a complication of care that remains after insurance benefits have been applied. Offering such a service to a patient, if eligible, does not constitute and shall not be construed as an admission of liability. PAS matters are not considered a medical liability claim, but rather a benevolent early intervention gesture. Eligibility is evaluated on a case-by-case basis and certain restrictions apply.
We encourage CAP members to call CAP’s Hotline at 800-252-0555 the moment an adverse event is recognized. Please have the following important information available for the CAP Cares specialist:
- Patient’s name and date of birth
- Date of the incident and location
- Names of other physicians or healthcare providers involved
- Description of possible injuries
Initially, there will be a discussion of appropriate immediate interventions and documentation. During future conversations, other interventions will be discussed, including apology, disclosure, and, if needed, arrangements for additional services the patient might need as a result of the adverse event. We assure you that any written and oral communications with you are confidential. We also remind you that any contact with CAP should never be written in the patient’s records.
We know that experiencing an adverse event can be very difficult and it is our intent to assist you during this very stressful time. Please call the CAP Cares Hotline at 800-252-0555 for help.
Amy McLain is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this ar ticle should be directed to amclain@CAPphysicians.com.