Medical Mutual Creates Compliance Toolkit for Physician Extenders

by David P. Sousa, JD, MBA, Senior Vice President and General Counsel

There are now more than 5,000 licensed Physician Assistants and Nurse Practitioners practicing in North Carolina, and their numbers will continue to grow in the years ahead. The Bureau of Labor Statistics projects that PAs and NPs will be among the fastest-growing occupations in the country between now and 2010. More ancillary providers mean greater exposures for our insured physicians and their practices, unless adequate measures are undertaken by the primary supervising physicians to oversee these employees.

State laws, including the Medical Practice Act (North Carolina General Statutes) and the Rules of the North Carolina Medical Board, clearly delineate many facets of the primary supervising physician's responsibilities. Do you know what those laws require of you? Are you aware that the North Carolina Medical Board is conducting site audits of practices throughout the state, checking for compliance with the laws regarding PAs and NPs? We have found that many practices are unaware of their legal obligations and the Medical Board's increased focus on physician extenders.

As we traveled across North Carolina for our Community Board meetings last fall and this spring, we tested the knowledge of our administrators and physicians, in practices large and small, as to PA and NP supervision requirements. Most practices acknowledged that their supervision procedures fall far short of the legal requirements. In order to proactively help you focus on these critical issues, Medical Mutual has created a toolkit to assist your practice in complying with the supervision laws.

The Physician Extender Toolkit was mailed in early July to all of our insured practices who employ any Physician Assistants or Nurse Practitioners. If you did not receive the toolkit or if you would like additional copies, please call Marina Calabrese at (800) 662-7917, ext. 7507. You may also request a toolkit if you do not employ PAs or NPs but would like to learn more about how we are educating our insureds on this important issue.

Once you receive the Physician Extender Toolkit, it is imperative that someone in your practice assume accountability for compliance with these legal requirements.

Help us help you by using this valuable and informative tool. We always want to hear from you, so please call us at (800) 662-7117 with any questions or comments you have about the toolkit or the supervision of physician extenders.

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Employee Dishonesty - Is Your Practice at Risk?

by Jim Kay, Vice President of Sales and Marketing

With the hectic schedules that physicians follow, many are happy to turn over the financial details of their practice to their staff. In a practice without the sufficient internal controls, however, that move could be very costly.

Employee embezzlement is an unfortunate trend that is on the rise across the country. According to the U.S. Department of Justice, internal theft within businesses totals over $60 billion a year. Medical practices are no exception and may even pose additional temptations due to the cash transaction nature of co-payments, deductibles and out-of-pocket payments. Some experts estimate that 3 out of 4 physicians will suffer a significant loss due to employee dishonesty at least once in their careers.

Even long-time, trusted employees have been caught stealing. Perhaps a $10 co-payment was "borrowed" to buy lunch. That could lead a seemingly honest but unscrupulous employee to think that if the missing $10 didn't show up in the books, maybe $50 wouldn't either. Soon, a trusted employee, but perhaps one who is resentful at what seems like a low salary, begins to siphon off small amounts of cash or deposits a few insurance checks into a personal account until it becomes second nature.

Many times, no one notices the missing revenue since the embezzler is often the one who records the payments and balances the books. In these cases, the practice does not have the appropriate checks and balances in place and the embezzling continues unnoticed. You may be concerned that your receipts aren't what they should be, but you may not be able to explain why.

It is important, where possible, to segregate duties and cross-train employees so that different employees handle and record cash. For example, many practices assign specific employees to open mail, prepare deposits, and post receipts to the practice management system. This creates a system of checks and balances in which no one employee has control over revenue, expenses, or inventory.

It is impossible to keep watch over your employees every minute of the day, but naively assuming they have your practice's best interest at heart could lead to financial distress, if not ruin. To protect your practice, it is crucial to implement the appropriate internal controls as well as to purchase "Employee Dishonesty" insurance coverage. This coverage may be the only way to recover losses if they do arise.

If you would like additional information on Employee Dishonesty coverage, appropriate controls for your practice to consider, or a list of potential warning signs, please contact Teri Breci at MMIC Agency, Inc. at (800) 662-7917, ext. 7587.

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A Review of Locum Tenens Replacement Coverage

by Sharon Musselman, ARM, Director of Underwriting

At times it becomes necessary for one physician to entrust another physician with the responsibility for treating some or all of his or her patients. Locum tenens means "holding the place of," and refers to one physician substituting for another. Medical Mutual provides free coverage for qualified, underwritten physicians who agree to substitute from time to time for an insured physician, and who have no separate individual coverage which would apply. The purpose of this benefit is to provide the insured physician with the ability to cover his or her practice while ill, on vacation, or receiving additional training. The insured physician and the locum tenens physician cannot work simultaneously, as only one individual is covered at any given time. The benefit may not be used to provide coverage for physicians assisting with call, nor should it be used to essentially extend the practice hours or capabilities.

The insured physician shares his limits of liability with the locum tenens physician during the period of substitution, so the insured physician should be diligent in selecting qualified locum tenens physicians to cover his patients. During the period of substitution, the insured physician should provide no professional services of any kind, as coverage during this period applies to the locum tenens physician only. There would be no coverage for any professional services rendered by the insured physician during this time. Extended reporting coverage (tail coverage) is included for the locum tenens physician as long as the policy remains in force, or when extended reporting coverage is purchased by the insured physician.

Coverage for the locum tenens physician is contingent on underwriting approval of a completed locum tenens application. The application is available on our website at www.medicalmutualgroup.com, or by calling us at (800) 662-7917. Coverage must be approved before the locum tenens is allowed to work, so it is important that the application is submitted to Underwriting in sufficient time for underwriting review and approval. The insured physician must sign the application authorizing the substitution of the locum tenens physician under his policy. The insured physician must also acknowledge the lack of coverage for professional services he might render during the period of substitution and the sharing of his limits with the locum tenens physician during the substitution period.

Locum tenens coverage is granted on a daily basis and should not exceed 30 days per policy year. If the locum tenens benefit is being used inappropriately, the benefit may be revoked. If you require locum tenens coverage in excess of 30 days per policy year, please contact your underwriter to discuss other options.

Please contact the Underwriting Department at (800) 662-7917 if you have any questions about this benefit of your coverage.

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TAKE 5 - Claims Case Offers Essential Lessons

by Naomi Tsujimura, RN, BSN, CCRN, Medical Care Analyst

As the largest insurer of North Carolina physicians, Medical Mutual is dedicated to helping our members provide the best possible care for their patients. Our commitment to you includes alerting you to claims trends and offering proactive strategies that can reduce your risk of a lawsuit.

The following claims review demonstrates five critical mistakes that could lead to a medical malpractice lawsuit. We hope that highlighting these issues will help you practice proactive risk management strategies with your own patients.

The patient, a 44-year-old female with a 24-year, pack-a-day smoking history, and a positive family history of CAD, presented to her local ED with complaints of chest pain. She was diagnosed with GERD and an URTI and told to follow up with her PCP (Primary Care Provider). The patient presented to her OB/GYN (whom she utilized as a PCP) for follow-up.

The OB/GYN placed the patient on medications for her GERD and her URTI; however, the patient had continuing complaints of chest pain and shortness of breath with exercise. The patient's OB/ GYN ordered an exercise stress test and requested that the results of the stress test be sent back to her office. A cardiology consult was not ordered. The stress test was read as positive in the inferior and lateral leads. This report was faxed back to OB/GYN office; however, the physician was on vacation for two weeks and the results were neither reviewed with another physician in the practice, nor communicated to the patient.

Upon the physician's return to the office, the stress test results were reviewed and the patient was then referred for a cardiolite stress test. The cardiolite test was administered by a technologist and nurse employed by the cardiology practice. The patient developed chest pain during the test and required a dose of nitroglycerin in order to complete the study. The results of the study were marked as "abnormal" by the nurse and placed in the reading physician's inbox. No physician within the group was notified of the patient's chest pain during the test, the use of nitroglycerin during the test, or the results of the test.

The following morning the reading physician reviewed the results of the study and interpreted them as grossly abnormal. Upon attempting to contact the patient, the practice was notified that after leaving the office the patient went to a restaurant where she was later found unresponsive on the bathroom floor. EMS was contacted but the patient was unable to be resuscitated. Autopsy results revealed a thrombus blocking the right coronary artery and several recent myocardial infarcts.

What five points can any practice take away from this scenario?

1. If you are a specialist, your patients need to have a PCP of record that they see for their PCP concerns and issues.
2. Order appropriate referrals and consultations with other providers should your patient present with problems and complaints that fall outside your specialty.
3. If a physician orders testing on a patient, the practice needs to have a fail-safe system in place that not only assures that results are received and reviewed by the ordering physician or another physician designee in a timely manner, but also assures that abnormal results and any additional treatment recommendations or follow-up are communicated to the patient.
4. If your practice performs in-office testing, staff members need to have successfully completed competency based training for the test as well as the policies and procedures associated with the testing.
5. If your practice performs in-office testing, procedures for physician oversight of the testing and prompt review of results need to be in place.

We hope you find this case review to be a valuable resource. If you have questions about how to reduce your risk of a lawsuit, please call our Risk Management team at (800) 662-7117.

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NCMGM Administrator of the Year: Robert Williams of Clinton Medical Clinic

by Stephanie Hawco, Director of Corporate Relations

The North Carolina Medical Group Management Association named Robert E. Williams "Administrator of the Year" at its Spring Conference in Myrtle Beach. The award, sponsored by Medical Mutual, honors a medical practice administrator for exceptional leadership, management skills, and enhancing health care delivery in North Carolina.

Williams (left) receives award from David Sousa, Senior VP and General Counsel for Medical Mutual

Williams has guided CMC through several major expansion projects, overseen the acquisition of a rural satellite clinic, and implemented a Rural Family Medicine Residency program. He successfully collaborated with numerous stakeholders to resolve the legal challenges associated with building an annex that houses exam rooms, office space and diagnostic services.

Dr. R.M. Herring, Jr., President of the Clinton Medical Group, also noted that Williams implemented an electronic medical records (EMR) system at a time when many CMC employees "didn't know a mouse from a possum." Under Williams' leadership, the Clinton Medical Clinic has been consistently recognized as a national benchmark practice by the Medical Group Management Association.

The Administrator of the Year Award includes a $2,000 stipend for continuing education. The NCMGM is a leader in education and professional growth for administrators, and Medical Mutual is proud to be its exclusive Diamond Level sponsor. The NCMGM Fall Conference will be held September 19th - 21st at the Grandover Resort in Greensboro.

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Medical Mutual Receives NCMGM President's Award

Cloninger (right) presents President's Award to Medical Mutual staff members

In presenting the award, Cloninger noted Medical Mutual's willingness to share its risk management expertise, commitment to securing needed health care legislation, and longstanding support of administrators and their professional growth.

The North Carolina Medical Group Management Association has over 600 members representing more than 225 medical groups, including small and large specialty groups, medical school clinics and other organizations. Medical Mutual is proud to be the exclusive Diamond Level sponsor of the NCMGM and we look forward to a long and healthy partnership between our organizations.

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Michael P. Moulton, MD Joins Medical Mutual Board of Directors

Medical Mutual is pleased to announce that Michael Paul Moulton, MD of Eastern Carolina Emergency Physicians has been elected to the MMIC Board of Directors. Dr. Moulton was elected to the Board by the physician members of Medical Mutual in April.

Dr. Moulton has been a practicing emergency physician at ECEP since 1994. He also serves as the President and Medical Review Officer of Medac Health Services, which owns and operates urgent care and occupational health centers in Wilmington. Dr. Moulton is Vice Speaker of the North Carolina Medical Society, a member of the NCMS Board of Directors, and an Alternate Delegate to the American Medical Association. Dr. Moulton was president of the New Hanover/Pender County Medical Society in 2005.

A native of Southern California, Dr. Moulton earned a bachelor's degree in Biology from the University of California at San Diego, a master's degree in Molecular Biology from San Diego State University and a medical degree from the University of Texas Health Science Center in San Antonio. He completed his residency at the Medical College of Pennsylvania in Philadelphia and is board certified in Emergency Medicine.

Before his election to the MMIC Board of Directors, Dr. Moulton served on Medical Mutual's Coastal Community Board. He lives in Wilmington with his wife Frankie and their children, Michael Paul and Kathleen.

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NCMS Employee Benefit Plan to Offer More Options for Physician Practices

The North Carolina Medical Society Employee Benefit Plan, available exclusively through MMIC Agency, Inc., is the only statewide health benefits plan designed specifically for North Carolina physicians and practices. When the upcoming plan year begins on August 1, 2007, you will find new benefits tailored to meet the needs of physicians and their employees. Some notable additions to the NCMS Plan include:

• The introduction of new coverage options, including health plans integrated with employer-funded Health Reimbursement Accounts (HRAs)
• The ability for larger practices to offer three health products to their employees, including two traditional PPOs and a health plan with an HRA or HSA (Health Savings Account)
• The expansion of our life insurance product lineup. Practices will be able to offer one flat amount, two flat amounts (giving employees the option to pay for a higher amount), or a multiple of salary (some restrictions apply)

For practices that renew on or after August 1, 2007, changes to the NCMS Plan will take effect upon renewal.

With the NCMS Plan, choice is your greatest benefit. To learn more about the unique combination of benefits provided by the NCMS Plan, please contact MMIC Agency, Inc. at (800) 662-7917, or visit us online at www.ncmsplan.com.

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Top Ten Ways to Guarantee a Lawsuit

by Amy Young, Risk Manager

Medical Mutual's Risk Management team usually focuses on strategies that prevent medical malpractice lawsuits. However, are you aware of the top ten ways to guarantee that you'll get sued? An interesting article in Medical Economics caught our eye recently. The article is titled "10 Ways to Guarantee a Lawsuit."¹

According to the article, the 10 ways to guarantee a lawsuit are:

• Don't worry about keeping detailed records
• Don't take the time to document informed consent discussions
• "Fix" records quickly when something goes wrong
• Trust the patient to follow through on referrals
• Don't bother to track test results
• Don't check the chart when ordering medication
• Don't say anything if something goes wrong
• Diagnose over the phone
• Don't care whether patients like you
• Assume each patient needs just a few minutes

The Risk Management department has developed a new educational toolkit based on this concept. The toolkit includes a DVD and educational booklet for use in training your office staff. The DVD tells the story of a malpractice case from the perspectives of the patient, the physician, and the office manager. The accompanying educational booklet reviews the issues highlighted in the case and relates them back to the "Top 10 Ways to Guarantee a Lawsuit." At the end of the booklet, you'll find a short test and answer key.

This toolkit can be used for orientation, competency training, and ongoing education of your office employees. If you would like a copy for your practice, please contact the Risk Management Department at (800) 662-7917.

¹Rice, Berkeley, "10 Ways to Guarantee a Lawsuit" Medical Economics, July 8, 2005, http://www.memag.com/memag/article/articleDetail.jsp?id=168737

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