Using an ERM Approach for Telemedicine and Telehealth Underwriting

Transcription

1 Using an ERM Approach for Telemedicine and Telehealth Underwriting By Fay A. Rozovsky Objectives Discuss Current and Projected Telemedicine & Telehealth Services. Examine Current & Projected Underwriting Risk Exposures in Telemedicine & Telehealth Services. Provide Enterprise Risk Management Underwriting Strategies for Telemedicine & Telehealth. 2 1

2 Current and Projected Telemedicine & Telehealth Services 3 Defining Telemedicine the use of medical information exchanged from one site to another via electronic communications to improve a patient s clinical health status. Telemedicine includes a growing variety of applications and services using two way video, , smart phones, wireless tools and other forms of telecommunications technology. American Telemedicine Association telemedicine/what is telemedicine#.vxh82 en5nc 4 2

3 Defining Telehealth Telehealth is the use of electronic information and telecommunications technologies to support long distance clinical health care, patient and professional health related education, public health and health administration. HRSA, 5 A Difference Without A Distinction? While [telehealth technologies] do not meet the Medicaid definition of telemedicine they are often considered under the broad umbrella of telehealth services. Even though such technologies are not considered "telemedicine," they may nevertheless be covered and reimbursed as part of a Medicaid coverable service. Phone Fax Remote Monitoring 6 3

4 Think About the Underwriting Risks Telemedicine Telehealth Two way electronic communications to improve a patient s clinical health status. Long distance support for clinical health care, patient and professional health related education, public health and health administration. 7 Think About Legal Regulatory Risks State Law Interstate Medical Licensure Compact Consent Scope of Practice Rules 8 4

5 Think About Legal Regulatory Risks II A state's existing Medical Practice Act and related regulatory laws apply once a physician obtains state licensure through the Compact. Therefore, a physician licensed by a state via the Compact pathway MUST abide by all of the laws, rules, and regulations of that state where the patient is located and the practice of medicine occurs. FSMB. Interstate Medical Licensure Compact Medical Licensure Compact %28FINAL%29.pdf 9 Think Federal Law & Medicine for Telemedicine III CMS Conditions of Participation for Hospitals and Critical Access Hospitals, Telemedicine Credentialing and Privileging. Final Rule, Federal Register 76(87): , May 5,

6 Think About Legal Regulatory Risks IV Hospital CAH Other Hospital Telemed Service Free Standing Telemed Service Relying on their credentialed telemed providers. Send them adverse event data. Send quality data to them. Evidentiary issues? Insurance? Relying on their credentialed telemed providers. Send them adverse event data. Send quality data to them. Difference: Not regulated by Medicare. Evidentiary issues? Insurance? 11 Think About Legal Regulatory Risks V Payment may not be made for a medical service (or a portion of it) that was subcontracted to another provider or supplier located outside the United States. For example, if a radiologist who practices in India analyzes imaging tests that were performed on a beneficiary in the United States, Medicare would not pay the radiologist or the U.S. facility that performed the imaging test for any of the services that were performed by the radiologist in India. Medicare Beneficiary Policy Manual, (Rev. 198, ) 60 Services Not Provided Within United States (Rev. 102; Issued: ; Effective/Implementation Date: ) 12 6

7 Telemedicine Examples Abound Teleradiology Telepsychiatry Teledermatology e ICU Telecardiology Telepathology Telepsychology 13 Patient Interface Telemedicine Patient dials in from home to 24/7 The Doctor is In Service. Patient at a Retail Clinic sees the nurse practitioner remotely. 14 7

8 Telehealth Examples Cardiac Event Monitor Home Health Diabetes Monitor Home Obstetric Monitor Home Congestive Hearts Monitor Patient Portals 15 Telemedicine: The Future? Or Now? Doctor is in a Western State conducting robotic surgery in a Midwestern State. Surgical procedure set up by team at the facility where the patient is receiving care. How many underwriting risk exposures do you see in this situation? 16 8

9 Telehealth: The Future? Or Now? Fitbit? Smartphone Tablet Apple Watch 17 Current & Projected Underwriting Risk Exposures in Telemedicine & Telehealth Services 18 9

10 Current Risk Exposures Negligent Diagnosis Negligent Treatment Missed Diagnosis Negligent Credentialing Corporate Liability Enterprise Liability Delay in Care Negligent Consent Lack of Consent 19 More Contemporary Risks Delegation Scope of Practice Billing & Coding Stark Issues HIPAA Violations Data Breach Professional Licensure Actions Contractual mhealth Technology Substandard Documentation Failure to Respond Fraud & Abuse 20 10

11 Future Risks, Anyone? New risks will turn on technology and users. New risks will involve emerging legislation & regulations. New risks may involve international telemedicine and telehealth applications. 21 Case Example: Contracting RIsk Community Hospital contracts with Quick Radiology Associates, a local group to manage and provide 24/7 imaging services. Unbeknownst to hospital, Quick Radiology subcontracts with Overnights, Inc., a publicly traded entity with radiologists in Switzerland, Australia, and India

12 Contracting Risk, Cont d Hospital finds out about the third party. Nothing in contract to prevent it. Asks for proof of insurance. Declaration Page refers to See Attached. Attachment includes 24 named insureds sharing $1/$3 million limits. SEC 10K report for Overnights, Inc. lists 3 lawsuits with awards or settlements totaling $7.5 million. 23 Contracting Risk Conclusion Within 18 months there are four diagnostic imaging lawsuits against Community Hospital that exceed Quick Radiology s limits. All involve 2 Switzerland based Overnights, Inc. providers. Enterprise Liability Negligent Credentialing Corporate Liability Insurance Limits Issue Reservation of Rights? 24 12

13 Case Example: Telehealth Monitoring Risks Nori Gould, a 79 year old retired executive was computer savvy. Afflicted with a number of chronic health ailments, she was very diligent about working with her telehealth monitor & patient portal. 25 Case Example: Telehealth Monitoring Risks II Nori found a sore on her left ankle. She took a photo of it, uploaded it to her patient portal and sent a note to Marge Janes, DNP asking, Is this anything I need to worry about, Marge? By Wilson44691 (Own work) [Public domain], via Wikimedia Commons 26 13

14 Case Example: Telehealth Monitoring Risks III Ms. Janes was on vacation in Europe. No one had been designated to monitor her patient portal notifications. The medical practice policy & procedure was ambiguous on the topic. Policy stated: Patient portals will be monitored on a regular basis. 27 Case Example: Telehealth Monitoring Risks IV Three days later, Ms. Gould repeated her portal question & received no response. When her niece visited her and saw the extent of the patient s wound, she took her to the local community hospital. You have a stage III wound, Ms. Gould, said the ED physician

15 Case Example: Telehealth Monitoring Risks V Notwithstanding aggressive therapy, Ms. Gould developed sepsis. A large segment of her foot was amputated. She developed multiple organ failure & died. Liability risk anyone? 29 Enterprise Risk Management Underwriting Strategies for Telemedicine & Telehealth 30 15

16 ERM in Perspective An ongoing decision making process instituted and supported by the healthcare organization s board of directors, executive administration, and medical staff leadership across the continuum of care to reduce uncertainty and process variability, promote patient safety, and maximize the return on investment (ROI) through asset preservation, value creation, and the recognition of actionable risk opportunities. R.A. Carroll, Editor in Chief, Enterprise Risk Management Handbook for Healthcare Entities, 2d ed. (Washington, DC: AHLA, 2013). 31 ERM in Action Risk Identification Surveillance Underwriting Plan & Implementation Risk Decision Risk Analysis Risk Evaluation 32 16

17 ERM in Underwriting First ask yourself: What are the categories of risk exposure (Risk Domains) that you underwrite? Second, look for granularity in each risk domain. Communication Denial of Service Data Hacking Data Breach Equipment Failure Equipment incapability No roll over capability by vendor No business contingency plan by insured Domain: OPERATIONS TECHNOLOGY 33 Underwriting ERM Process Steps I Identify Risks in each domain. Analyze the risks from an underwriting perspective. Evaluate the risks from an underwriting standpoint: Is this a good risk for us? 34 17

18 Underwriting ERM Process Steps II If you want the risk (insured) are there measures to require for: Risk Avoidance Risk Mitigation? Lessening frequency? Lessening Severity? 35 ERM Tools of the Trade Used by Your Insureds Risk Inventories: Interviews, self assessment forms, group brainstorming. FMEA Style Analysis SWOT Analysis GAP Analysis Root Cause Analysis ERM Risk Evaluation Matrix Risk Analysis: for each risk domain an array of tools can be used that best meets the need of the organization. Risk Mapping ERM Heat Map Visual graphing of evaluation & recommendation 36 18

19 ERM Telemedicine/Telehealth Underwriting I Remember Appetite for Risk? TCOR (Total Cost of Risk )? ERM Underwriting and Insureds use these two concepts. The ERM tools are applied against the backdrop of Risk Appetite and TCOR. 37 ERM Telemedicine/Telehealth Underwriting II Use ERM to identify is this an acceptable risk for you. Can the prospect make improvements to become a better underwriting risk? Are there segments of the telemedicine/telehealth model that are not acceptable? 38 19

20 Education & Communication Education: ERM Fundamentals for all who are involved in the underwriting process. Messaging: to brokers, agents, insureds & prospects. Collaboration: Time to be a thought leader using the same tools as the field. 39 An ERM Underwriting Checklist Develop your own Underwriter s ERM Checklist of what you need to make informed analyses and evaluations with a view to the ROI for your company. On a computer, tablet or paper. Work collaboratively to get the information you need to gather the information you need for your work. See Sample Tool in Resource Material Section

21 Conclusion 41 Telemedicine & Telehealth Underwriting A very dynamic area of healthcare. Anticipate internal, external, and legal regulatory changes to continue to define the landscape. Become a knowledge leader to better define and underwrite these risks

22 We Welcome Your Questions Please use the microphone so others may hear you. Resource Information 44 22

23 Resource Books CONSENT TO TREATMENT: A PRACTICAL GUIDE, 5TH EDITION. New York: Wolters Kluwer Law & Business, 2015 (with regular supplements). ENTERPRISE RISK MANAGEMENT HANDBOOK FOR HEALTHCARE ENTITIES, 2D ED. (Washington, DC: AHLA, 2013). HEALTH CARE ORGANIZATIONS RISK MANAGEMENT: FORMS, CHECKLISTS AND GUIDELINES, 3RD EDITION. NEW YORK: Wolters Kluwer Law & Business, 2009 (with regular supplements). HEALTH CARE CREDENTIALING: A GUIDE TO INNOVATIVE PRACTICES. New York: Wolters Kluwer Law & Business, 2007 (with regular supplements). 45 Association Resource Information American Health Lawyers Association (AHLA) American Society for Healthcare Risk Management (ASHRM) American Telemedicine Association (ATA) Federation of State Medical Boards (FSMB) National Association for Medical Staff Services (NAMSS)

24 Accreditation Resource Information ATA Accreditation Program for Online Patient Consultations patient consultations/program home#.veye5xun7hk National Committee on Quality Assurance The Joint Commission 47 Federal Resource Information Centers for Medicare and Medicaid Services Center for Medicare & Medicaid Innovation (the Innovation Center) CMS Conditions of Participation for Hospitals and Critical Access Hospitals, Telemedicine Credentialing and Privileging. Final Rule, Federal Register 76(87): , May 5, Medicare Beneficiary Policy Manual, (Rev. 198, ) 60 Services Not Provided Within United States (Rev. 102; Issued: ; Effective/Implementation Date: ) State Operations Manual Appendix A Survey Protocol, Regulations and Interpretive Guidelines for Hospitals (Rev. 141, ) and Guidance/Guidance/Manuals/downloads/som107ap_a_hospitals.pdf 48 24

25 Sample ERM UW Checklist: Telemedicine/Telehealth 49 Sample ERM UW Checklist: Telemedicine/Telehealth 50 25

26 Contact Information Fay A. Rozovsky, JD, MPH The Rozovsky Group, Inc Reades Way Williamsburg, VA (860)