Martin Bree Senior Partner. Triton Group, LLC. Triton Group, LLC.

Transcription

1 Federal Trt Claims Act and Risk Management West Virginia Primary Care Assciatin August 6, 2009 Martin Bree Senir Partner.. Tritn Grup First Surce f FTCA Prgram Infrmatin Tritn Grup 227 Hamburg. Pmptn Lakes, NJ HRSA Cntract N Martin J. Bree Susan Lewis (fax) susanlewis@tampabay.rr.cm (cell) mjbtritn@mac.cm Rger Fuydal 866-FTCA-HELP - Tll Free Marty Hiller (Free Clinics) ( ) (Fax) mhiller862@htmail.cm tritngp@ptnline.net. 1

2 Federal Trt Claims Act A limited waiver f the federal gvernment's svereign immunity when its emplyees are negligent within the scpe f their emplyment Impses liability n the United States in the same manner and t the same extent as a private individual under like circumstances law f the place where the act r missin ccurred applies (except federal prcedural law). Federal Trt Claims Act (cnt.) Cannt bring suit fr intentinal trts (e.g. assault, battery, false imprisnment, etc.) r vilatins f cnstitutinal rights under the FTCA. N limitatin f liability under FTCA Prvides fr judicial as well as administrative remedy Punitive damages and prejudgment interest nt allwed N jury trials. 2

3 Federal Trt Claims Act (cnt.) Administrative Claim Requirement must file a claim with agency and give pprtunity t the agency t settle claim befre a suit is permitted If Agency denies, takes n actin after six mnths, r ffers unsatisfactry amunt, claimant may bring suit in against U.S. in federal district curt (within 6 mnths) Attrney fees limited t 20% f administrative settlement and 25% f judgment r cmprmise settlement. Federally Supprted Health Centers Assistance Act FSHCAA - Health Centers are eligible t be deemed federal emplyees. Prvides immunity frm lawsuit alleging medical malpractice. Plaintiff s nly remedy is claim under Federal Trt Claims Act (FTCA).. 3

4 FSHCAA (cnt.) A scheme that prvides immunity frm lawsuit. Appears similar t an ccurrence malpractice plicy. Prgram in existence fr 16 years. Very successful in terms f savings fr health centers and cverage f health centers and staff.. FSHCAA (cnt.) Wh is Eligible t be Deemed: Cmmunity Health Centers [sectin 330 (e)]. Migrant Health Centers [sectin 330 (g)]. Health Care fr the Hmeless [sectin 330 (h)]. Public Husing Primary Care [sectin 330 (i)]. 4

5 FSHCAA (cnt.) Wh is cvered - Emplyees All emplyees, full time r part time. Vlunteers are nt emplyees. Emplyees get a W-2 at end f year. FSHCAA (cnt.) Wh is cvered - Cntractrs Any full time cntract prvider (ver 32 1/2 hurs per week). Part time cntract prvider f services in the fields f family practice, b-gyn, general internal medicine, r general pediatrics. Cntract must be between the deemed health center and the individual prvider. Cntracts between the deemed health center and a crpratin (including Prfessinal Crpratins) are nt cvered. 5

6 Cntractrs FSHCAA (cnt.) 42 U.S.C. 233(g)(1)(A) any cntractr f such an entity wh is a physician, r ther licensed r certified health care practitiner. 42 U.S.C. 233 (g)(5) an individual may be cnsidered a cntractr. What is Cvered Medical malpractice. Mre specifically, medical, surgical, dental and related activities (if within the scpe f emplyment and scpe f prject). 6

7 Scpe f Prject Very Imprtant Only incidents that ccur within the scpe f the prject are cvered. (See Plicy Infrmatin Ntice ). Scpe f Prject are the activities described in the grant applicatin that are apprved by Public Health Service via Ntice f Grant Award. An existing Scpe f Prject cannt be changed in a grant applicatin. There is a separate prcess. A grant award fr a new sectin 330 activity des change the Scpe f Prject. Scpe f Emplyment When is it cvered Cverage is nly fr acts that are within the scpe f emplyment f the cvered individual. N Mnlighting. Must be acting n behalf f the deemed entity. 7

8 FTCA Prcedures Prcedure Plaintiff files administrative claim against the United States. DHHS reviews claim and may deny it, pay it r ffer a settlement. If DHHS denies claim plaintiff may file suit. If DHHS des nt act n claim within six mnths plaintiff may file suit. When suit is filed case transferred t DOJ. DOJ may attempt t settle suit therwise it ges int litigatin. FTCA Prcedures Prcedure Plaintiffs ften file suit in state curt. What t d: Immediately fax cmplaint and deeming letter t: Meredith Trres Department f Health and Human Service Office f General Cunsel (OGC) (Fax) (Vice) Have health center attrney request extensin f time t reply. 8

9 Ptential Prblems Cntracts. C-Applicants Sub-Recipients. Scpe f Prject - Sites and Services. Billing Arrangements. Emplyment Cntract Language. Nursing Hmes. Cntracts with Crrectinal Institutins. Nn-Health Center Patients. Nn-Health Center Patients Federal Register Ntice September 25, 1995 (Vlume 60 Number 185) page Hspital On-Call Requirements. Crss Cverage Arrangements. Cmmunity Activities. Other situatins require a Particularized Determinatin See

10 Hspital On-call Requirements September 25 FRN states that the Secretary has determined that cverage extends t: Peridic hspital call r hspital emergency rm cverage, as required by the hspital as a cnditin fr btaining hspital admitting privileges. There must be dcumentatin fr the particular health care prvider that this cverage is a cnditin f emplyment at the health center. Crss Cverage Activities September 25 FRN states that the Secretary has determined that cverage extends t the fllwing situatin: As part f a health centers arrangement with lcal cmmunity prviders fr after-hurs cverage f its patients, the health center s prviders are required by their emplyment cntract t prvide peridic r ccasinal crss-cverage fr patients f these prviders. 10

11 Cmmunity Wide Interventins Schl-Based Clinics. Schl-Linked Clinics. Health Fairs. Immunizatin Campaign. Migrant Camp Outreach. Hmeless Outreach. Particularized Determinatin A Particularized Determinatin is a request fr prir apprval f FTCA cverage fr care t a nn-health center patient. The Sept 25, 1995 FRN states If any element f the activity r arrangement in questin des nt fit squarely int the examples belw, a particularized determinatin n cverage shuld be sught. 11

12 Imprtant issues Insurance requirements f hspitals and Health Maintenance Organizatins. Natinal Practitiner Data Bank. Other Insurance. Deeming Applicatins. Credentialing a critical issue. Specialty Care. Emergency Respnse - PIN Insurance Requirements f Hspitals and HMO s. 42 U.S.C. 233(j) - Remedy fr denial f admitting privileges t certain health care prviders. 42 U.S.C. 233(m) - Applicatin f cverage t managed care plans. 12

13 Natinal Practitiner Data Bank (NPDB) HRSA Participates in the NPDB. 42 U.S.C Assistant Secretary f Health elects t require PHS agencies t reprt Octber Other Insurance Needs Gap r Wrap-arund: cvers medical malpractice nt cvered by FTCA. Vlunteers Outside Scpe Cntracts with crpratins Cntracts with part time specialists Tail Insurance General Liability Insurance Directrs and Officers Liability Prf f malpractice cverage Tritn Grup 13

14 Deeming Applicatins 2009 Plicy (fr deeming year CY 2010) Applicatins due n July 17, Electrnic applicatin, similar t grant applicatin. Reviews will be cmpleted by cntractr with recmmendatins t BPHC. Prgram Value Malpractice Premium Savings Studies cnducted fr Tritn Grup by Princetn Insurance Cmpany and Huggins Actuarial Services. Premiums calculated fr 2002, 2005, 2006 Used Unifrm Data System (UDS) data fr deemed Health Centers 14

15 Prgram Value Malpractice Premium Savings Study Methdlgy Used Occurrence Premiums with $1m/3m limits. Premiums include 25% fr taxes, prfits, cmmissins, etc. Each deemed Health Center rated by its specific territry. Rates based n Full Time Equivalents by specialty. Premium increased by 10% t cver crpratin and allied persnnel. Prgram Value Malpractice Premium Savings Study Results 2002 Savings fr deemed centers - $164,000, Savings fr deemed centers - $180,000, Savings fr deemed centers - $184,000, Savings fr deemed centers - $192,000, Savings fr deemed centers - $204,000,000 Extraplating frm the studies: ttal savings since 1993 $1.75 billin 15

16 Claim Status - Natinal Oct thru April Clsed Claims - apprximately 65% f ttal. Paid Claims apprximately 33% f ttal claims, 50% f clsed claims Avg. cst per paid claim - $400,000. Avg. cst per clsed claim - $210, HRSA FTCA CLAIMS PER FISCAL YEAR 16

17 Risk Management Health Centers are expected t use a prtin f savings t prvide risk management services. (PIN Para. XVIII). Inspectr General reprt n risk management in health centers. Tritn Grup can prvide risk management services. 17

18 HRSA Risk Management Requirements Active Quality Imprvement Prgram Apprpriate use f clinical prtcls Clear cmmunicatin with patients Cmprehensive patient medical recrds Credentialing and privileging f health care prfessinals Frmal patient grievance mechanism Regular patient satisfactin survey Regular staff training n risk management Up t date plicies and prcedures n risk management Risk Management Issues in Health Centers Credentialing and Privileging g Cmpetence f prviders Medical Recrds Legibility Cmpleteness Signatures Availability Birth Injuries Existence and Prper use f prtcls Infrmed Cnsent 18

19 Credentialing and Privileging PIN Credentialing and privileging il i required f all licensed r certified health care practitiners. Prcess fr Licensed Independent Practitiners (LIPs) generally mimics JCAHO. Nn-LIPs requires primary surce verificatin f nly license r certificatin. Vlunteers included. HIPAA Sectin 194 Vlunteers in Free Clinics Prvides Med Mal prtectin t Vlunteers in Free Clinics Vlunteer and free clinic are specifically defined in the statute Des nt cver the free clinic crpratin nr the free clinic emplyed staff Free clinic i may nt accept any third party reimbursement Must give ntice t patients n limitatins f liability 19

20 Tritn Grup First Surce f FTCA Prgram Infrmatin Tritn Grup 227 Hamburg. Pmptn Lakes, NJ HRSA Cntract N Martin J. Bree Susan Lewis (fax) susanlewis@tampabay.rr.cm (cell) mjbtritn@mac.cm Rger Fuydal 866-FTCA-HELP - Tll Free Marty Hiller (Free Clinics) ( ) (Fax) mhiller862@htmail.cm tritngp@ptnline.net 20