Health Care Risk Management: Organization and Claims Administration

Health Care Risk Management: Organization and Claims Administration

by Gary P. Kraus
     
 

ISBN-10: 1587980185

ISBN-13: 9781587980183

Pub. Date: 06/28/2000

Publisher: Beard Group Inc.

More than ever before, health care facilities and professionals need to guard against unexpected financial losses from casualty, worker's compensation, and professional liability. Risk management is that complex set of tasks, functions, and decisions carried out with the objective of reducing such losses. The field of risk management in the health-care industry

Overview

More than ever before, health care facilities and professionals need to guard against unexpected financial losses from casualty, worker's compensation, and professional liability. Risk management is that complex set of tasks, functions, and decisions carried out with the objective of reducing such losses. The field of risk management in the health-care industry developed out of the deluge of malpractice cases which stunned the medical community in the late 1960s and led to soaring insurance claims and premiums.

This book treats all the broad and divergent elements of health care risk management, and is aimed at students, instructors, management, and health professionals alike. Risk management is divided into three processes: exposure of risk identification; risk measurement or evaluation; and risk handling or treatment. Managers first analyze exposure areas of an organization so that risks contained within it can be identified. Next they evaluate the risk by applying analytical skills and decision-making techniques to the risk areas to determine their potential for occurrence and the inherent financial impact. Finally, managers decide how the risks that have been identified and measured are to be handled by the organization. Risk handling includes risk financing, which may include retention, transfer, and self-financing of risks and exposure areas; and risk control, which includes avoidance, shifting, and prevention of risks.

The text provides meaningful exercises, extensive references, and a comprehensive glossary of terms. It is well balanced, thorough, and provides an excellent overview of its subject.

Product Details

ISBN-13:
9781587980183
Publisher:
Beard Group Inc.
Publication date:
06/28/2000
Pages:
348
Product dimensions:
5.50(w) x 8.50(h) x 0.78(d)

Table of Contents

Contributorsxi
Forewordxiii
Prefacexv
Acknowledgmentsxvii
Chapter 1Introduction to Risk Management1
Definition and Purpose1
The Risk Management Process3
Summary16
Chapter Exercise16
Questions18
References19
Chapter 2Risk Management Program Design21
Organizational Models22
Interinstitutional Relationships31
Risk Management and Quality Assurance35
The Role of the Medical Record Department in Quality Assurance40
Internal Office Organization47
The Risk Management Committee50
Summary54
Chapter Exercise55
Questions55
References56
Chapter 3The Risk Manager57
Role of the Risk Manager57
Educational and Experience Prerequisites63
Job Descriptions and Compensation68
Professional Societies and Credentialing71
Summary75
Chapter Exercises75
References75
Chapter 4The Risk Management Information System77
Risk Management Communications77
Incident Screening86
Computerized Filing and Report Systems89
Summary95
Chapter Exercises95
References96
Chapter 5A Summary of Health Provider Liability Law97
Fundamentals of Liability Law97
Corporate Negligence106
Respondeat Superior107
Informed Consent110
Privacy and Confidentiality118
Antitrust Law120
Labor and Personnel Issues123
Medical Staff Issues128
Workers' Compensation Law132
Summary142
Chapter Exercises143
References144
Chapter 6Adverse Occurrence Screening and Investigation149
The Potential Compensable Event151
P.C.E.s and Occurrence Screening153
Record and Evidence Preservation157
Inquiry Procedures159
Witness and Actor Interviews162
Case Verification164
Case Evaluation and Decision Making165
Summary168
Chapter Exercise169
Questions169
References169
Chapter 7Strategy, Settlement Techniques, and Litigation Defense171
Lawsuit and Claims Management Filing System172
Relationships with the Insurance Company175
Prelitigation Strategy178
Plaintiff Strategy180
Ethical, Legal, and Administrative Considerations183
Settlement Techniques185
Risk Management and Defense Counsel187
Releases and Related Instruments189
Structured Settlements193
Summary197
Chapter Exercises198
References199
Chapter 8Developing and Implementing a Comprehensive Risk Prevention Program201
Defining Risk Prevention Activities201
Setting Institutional Priorities202
Addressing Institutional Priorities215
A Selection of Literature on Risk Management, Law, and Quality Assurance220
Summary223
Chapter Exercise223
References224
Chapter 9The Medical Record and Risk Management227
The Importance of the Medical Record227
The Purpose of the Medical Record228
Failure to Comply with Minimum Requirements for Medical Record Keeping229
Rules of Medical Record Keeping230
Risk Management Uses of the Medical Record241
The Medical Record and Confidentiality of Patient Information244
The Medical Record Department's Role in Risk Management248
The Role of Medical Record Practitioners in Risk Management251
Suggestions for Improved Medical Record Maintenance254
Summary255
Chapter Exercises255
References256
Chapter 10Risk Management in the Future259
The Liability and Malpractice Crisis259
Legislative Reforms and Curative Measures264
Early Dispute Resolution: Model for an Internal Program269
Summary274
Chapter Exercises274
References275
Glossary of Legal and Insurance Terms277
Index321

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