Sugar and Spice: Preventing a Complaint from Snowballing into a Claim

How does that old saying go? “A spoonful of sugar makes the medicine go down” (Mary Poppins, 1964).  When it comes to customer service, this saying rings true. The moment a patient calls your office, the interaction leaves a lasting impression of your practice and your staff, and can ultimately spill over to you, the provider. Physician practices face many challenges today, and one common challenge is managing a patient complaint. In April 2021, CAP presented a webinar titled The Ins and Outs of Managing Patient Complaints.  The focus was on three areas:

  • The Patient Experience: Customer Service
  • Managing Difficult Patients and Situations: Understanding the Grievance Process
  • Discontinuing the Physician-Patient Relationship: When to Consider and Understanding the Process

CAP knows receiving a complaint from a patient can be very stressful.  While it is nearly impossible for any practice to avoid the occasional unhappy patient, how physicians and their staff handle a patient’s concern can impact both your liability risk and your bottom line. 

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When a patient complaint is "ignored" or in the mind of the patient "discounted," the issue escalates. Viewing patient complaints and grievances from the patient point of view is imperative, regardless of whether a concern appears legitimate or not. If the patient feels the concern sufficiently to voice it, the complaint should be taken seriously and treated as such (ECRI 2016). “Complaints carry a certain validity simply by virtue of being the perception of the patient or family member” (ECRI 2016). Unaddressed grievances can escalate into a Medical Board inquiry, insurance grievance, poor social media posting, or even snowball into a claim. Litigation is extremely time-consuming for physicians, in addition to being emotionally distressing. 

When patients lodge a grievance, it is important to have an office policy and process for management of the grievance. At a minimum, your practice should have mechanisms in place to:

  1. Inform the patient of the complaint process.
  2. Receive and respond to complaints in a timely manner.
  3. Implement corrective actions as necessary to resolve the complaint.
  4. Reassure the patient that future care will not be compromised due to a registered complaint. 

The process should identify the person in the office who will take the lead on the grievance process as follows:

  • Complaints about medical care should involve the physician or provider. 
  • Billing concerns should be referred to the account representative or billing department.
  • Other concerns should be given to the administrator or designee. 

All physicians and staff should be educated on the office grievance process and trained to listen effectively and manage patient and family expectations (ECRI 2016). It is important that your patients know you’re genuinely interested in their feedback to improve the patient experience and respond appropriately to issues.  Below are additional tips for responding to complaints. 

  • Don’t avoid the patient 
  • Keep communication open
  • Involve the patient in the process
  • Treat the patient with dignity, courtesy, and privacy during the complaint-handling process
  • Allow the patient to state the problem completely without interruption or argument
  • Thank the patient for bringing the concern to your attention
  • Make a statement of empathy without admitting fault or placing blame (e.g., “I’m sorry your wait time today was longer than expected”)
  • Do something for the patient
  • Reassure the patient that you take all concerns seriously
  • Assure the patient a full investigation will be completed
How CAP Supports Members

Complaints and grievances come in all sizes and shapes. In our experience at CAP, a portion of grievances accompany a request for a refund and/or charges for additional care to be covered by the member. CAP has a team dedicated to assist our members with grievances — our CAP Cares team. The CAP Cares team can help you navigate a complaint to reduce your liability risk and determine if there is any potential liability, with an end goal of maintaining a positive physician-patient relationship as well as preventing the grievance  from escalating into a claim.  

An example of how the CAP Cares Team can assist a member is our Patient Assistance Service Program (PAS). PAS is a no-fault, early intervention program designed to assist patients with expenses associated with complications of medical care — specifically copayments, coinsurance, deductibles, and other related costs. Certain criteria must be met for this program and is evaluated on a case-by-case basis by a CAP Cares specialist. Here is an example of the PAS program in action:

Patient Ms. A had a lesion removed from a digit. Immediately after the procedure, she suffered a vascular compromise of the digit, which was determined to be a very rare reaction to lidocaine. The vascular concern on the tip of her digit did not fully recover with the interventions provided in the office. The patient was referred to a tertiary care center for treatment with a hand specialist.  She required almost daily visits for hyperbaric treatment for two weeks, medications, and monitoring. Ms. A complained to the physician and his office manager that she had to drive a significant distance to receive the treatment, was accumilating multiple medical bills, as well as the emotional crisis of potentially losing the tip of a digit. Ms. A asked the physician to help pay for her treatment. She also mentioned she was unhappy she was not informed of this potential complication of the procedure. As this was a very rare complication, it was not discussed during the informed consent process. The PAS program reimbursed the patient's unexpected out-of-pocket financial costs related to this known rare complication. Total reimbursement by the PAS program was $2,963.80, which included:

$1,881.98 – Tertiary care (physician/hospital/hyperbaric)

$867.82 – Pharmacy and supplies

$214.00 – Parking cost

Ms. A was satisfied and appreciative of the member's assistance with her complaint. She made a full recovery after months of treatment and monitoring.

The physician-patient relationship was maintained.  It is important to note that PAS cases are not considered to be claims, but rather as a goodwill gesture by the member, and will not appear on a member’s “claims history.” Reimbursements made to a patient under typical PAS circumstances are not reportable to the Medical Board of California. 

This is just one example of how the CAP Cares team has helped CAP members manage a grievance. Sugar and spice can make everything nice; responding to complaints with sugar, and adding a little spice for the patient can, in the end, help you make everything nice. 

This information is provided as a service to CAP members from a risk management perspective and is not intended as legal advice. If you have questions or a specific patient situation and need guidance, please contact the Hotline at 800-252-0555. The CAP webinar, The Ins and Outs of Managing Patient Complaints, is available for on-demand viewing here.


Rikki Valade is a Senior Risk Manager for CAP. Questions or comments related to this article should be directed to rvalade@CAPphysicians.com.

 

References: 

Constantine, D., Kichler, D., & Mayhan, C. (2021).  Webinar: The Ins and Outs of Managing Patient Complaints. Cooperative of American Physicians, Inc.

Executive Summary (2016).  Managing Patient complaints and Grievances.  ECRI https://www.ecri.org/components/HRC/Pages/PtSup1.aspx?PF=1&source=print

Loomis, Julie RN, JD (2021).  Turning a Negative into a Positive:  Managing Patient Complaints, SVMIC  https://home.svmic.com/resources/newsletters/127/turning-a-negative-into...

Nacierio, Steven Esq. Small Business Digest (2021) http://smallbusinessdigestmag.com/content/five-tips-reducing-risk-litiga...

Sherman, Richard M. Mary Poppins 1964.  The Disney Wiki (2021) https://disney.fandom.com/wiki/Richard_M._Sherman.