The change in a Neurologists Practice:
Speaking with one of our Neurologists recently, he wanted to know if he should continue his ‘conventional’ medical malpractice insurance policy. This policy protected him in the practice of medicine, like so many other physicians: The generally One Million Dollar policy responds when there is an allegation made against the Neurologist for misdiagnosing, delayed diagnosis, or some claim of injury resulting from neurology services provided.
The Old practice, but with Telemedicine Technology
Like other specialties, Neurologists practice conventional clinic hours,seeing patients in their offices, attending to in patients at hospitals and consulting many other specialties. Because Neurology is a subspecialty, they can bring their service over the ‘wire’; receiving high resolution, quality images through web portals, or email, the practice of Telemedicine in the specialty of Neurology is growing. Telemedicine lends itself well to this specialty.
In this recent conversation, this Neurologist was contemplating two areas of ‘service’ which differed from his 30 years of practicing medicine:
1) Overseeing a scanning procedure using imaging technology to detected nerve function by monitoring response to stimulation of feet and legs.
2) Telemdicine Contract where he Receive emails with files of images to review and provide opinion through a telemedicine site.
What type of Insurance is needed?
The question that he raised: Does my current medical malpractice policy cover these two practices?
In this instance, it depends upon whether or not he advised his current carrier about this new practice model. Usually, the conventional malpractice companies will require that the physician establish a patient relationship through an onsite, ‘in person’ evaluation.
If there is no physician patient relationship, the malpractice insurance policy may not respond to a claim.When a physician is only providing protocol supervision acting exclusively in an administrative capacity, he is not likely to ‘trigger’ the policy.
And, since he did not see himself returning to the ‘old style’ of practicing Neurology as he knew it, he was better off cancelling his policy:
TWO POLICIES: Administrative Medicine and Telemedicine Liability Insurance Policy
So, we advised that he apply for a policy which would cover him for his telemedicine only neurology practice.
Additionally, we found a policy for just $ 1,000 per year to protect him against claims for supervision. This type of policy is common for physicians asked to serve as medical directors for laboratories, imaging centers, surgery centers, nursing homes, or other outpatient, or specialty facilities.
Telemedicine for Neurologists Increases Access to care:
This practice of Internet Telemedicine and Supervision only is becoming increasingly more common. The telemedicine practice for Neurologists brings their difficult to obtain services to more patients, eliminating wait time for appointments and providing increased access to patients living outside of city centers (where specialty care is more likely to exist). For the physician who wants to remain independent, this model allows a Neurolgist to receive files, provide consultations and schedule conference calls from their current independent office or home office.
Patient Safety in Telemedicine:
There are still Risk Management concerns in the practice of Telemedicine, or Supervisory Neurology (as we’ll call it). A practicing neurologist, working from home, providing administrative protocol and oversight, and telemedicine consultations still needs to practice carefully; paying attention to basic risk management principles of careful communication and documentation.
The Doctors’ Company (if they are the company that insures your telemedicine practice) or Admiral, or Catlin, and others provide fantastic resources for communication, documentation and prudent handling of electronic records.
While telemedicine can improve care by allowing quick access to specialists, it can also create some challenges in providing the same assurance of quality. For those using telemedicine it is important, when managing the risk, to check on the adequacy of credentials and constantly review the care provided by contracted specialists by working hard on effective communication and ongoing quality assessment.
CMS new Telemedicine Rules and Guidelines
The Centers for Medicare and Medicaid Services (CMS) in July 2011 issued the new telemedicine rules for hospitals and critical access hospitals. Their revisions to the Conditions of Participation (CoP), require that specific standards be met.
The new rules require a written agreement between the hospital seeking telemedicine services and the remote site hospital or entity. Core provisions of the written agreement include:
- The distant site hospital or entity providing the telemedicine services must be a Medicare participating hospital or meet all applicable COP including Medicare credentialing standards.
- The individual distant site practitioner providing the telemedicine services is privileged at the distant site hospital or entity which provides a current list of the distant site physician’s privileges at the distant site hospital or entity.
- The telemedicine physician holds a license issued or recognized by the state in which the hospital whose patients are receiving the telemedicine services is located.
- The hospital reviews telemedicine services provided to its patients by telemedicine physicians covered under the agreement and provides written feedback to the hospital or entity; addressing adverse events and patient complaints resulting from telemedicine services.
Some risk exposures that should be considered in managing risk of your telemedicine processes:
- Informed consent must be comprehensive, allowing patient choice to accept or decline telemedicine care.
- Non-physicians participating in telemedicine services may exceed the scope of their certification or license, resulting in unmet standards of care.
- Peer review protections may not extend to information shared between the originating hospital and remote telemedicine site.
- Do you have a Technical Professional Liability policy to protect the organization from errors that stem from the design of the telemedicine software and systems.
- Contemplate incidents of negligent credentialing, privacy breaches, and disruption of telemedicine services due to equipment failure or other reasons
- Develop guidelines regarding the type of medical information to be shared with remote practitioners who provide telemedicine interpretation and services.
Since you’re going to be purchasing a new policy (one to cover the Telemedicine practice and one to practice the supervision and administrative practice, you should understand the difference between a claims made and occurrence policy. Although each type of policy has components of the other within it.
There are differences that are important to understand:
Occurrence coverage means the policy covers claims from events that occur during policy period or while the policy is active. The key element of an occurrence policy is that it is more expensive and allows you to cancel the policy without purchasing an extended time to report endorsement (TAIL) policy.
In a claims-made coverage, the event has to occur and the complaint has to be made during the time when the policy is active. Claims-made coverage is less expensive, but, according to the type of claims made policy, it may require the purchase of expensive tail coverage at a later date. Tail coverage extends the claims reporting period after the policy is ended.
The elements of an Insurance Policy for Neurology Practice
The insurance policy covering a Neurology practice usually has four parts to it:
- A declarations page
- The conditions which discuss what is covered
- Exclusions
- Endorsements
The Declarations and agreement conditions will outline what and who is covered (and for what limits)
What is important in these Telemedicine policies and Administrative Medicine Policies is that the application becomes part of the legal contract, in the application you can state what it is you would like to have covered; example: ‘I will be supervising Neurological Scans, LLC, ensuring proper systems are in place to stabilize the patient and safely administer the stimulation necessary to evaluate the function of the spinal cord’
We do this by placement of sensor pads on the feet and legs which upload reactions to our software’. The policies can be THAT specific. ..which helps to assuage any concern that your coverage will not respond in the event of a claim. When comparing the costs of policies, pay careful consideration to types of coverage; policy limits; venue and available discounts.