5 Top Insurance Claims For Healthcare Practices in 2023 (And How to Avoid Them)

When we look at the most common insurance claims for healthcare practices in 2023, we see how a changing world brings new challenges and risks.

Recently, a healthcare leader from a large OB/GYN practice noticed a problem. During the pandemic, his nurse triage team had become accustomed to working out of the scope of practice. Knowing this put the organization at risk, he arranged for the team to join a webinar with Gigi Avecedo-Parker, an advanced practice nurse and national clinical risk management leader at Hub International.

“We can’t rely on experience,” says Avecedo-Parker, summarizing the key takeaway. “We rely on scope.”

Scenarios like this have become all too common since the beginning of the pandemic when needs were acute and staffing shortages were widespread. With the end of the state of emergency on May 11, now is a good time to take stock of what’s changed in your organization. Consider what has improved your practice – like telehealth – and what has put you at greater risk – also, perhaps, telehealth.

No healthcare practice is immune to the threat of lawsuits, but there are ways to reduce the risk. Let’s examine five of the most common liability insurance claims and the steps your practice can take to avoid them.

 

Claim 1: Workplace violence

 

When an active shooter attacked a physician’s office in Atlanta, the violence made front-page news. But the truth is that workplace violence occurs in healthcare settings every day.

• According to Press Ganey, a renowned leader in patient, member, employee and consumer experience, more than two nursing personnel were assaulted every hour in the second quarter of 2022.
• Healthcare and social service industries have the greatest rates of workplace violence injuries, with workers in these industries being five times more likely to be injured than other workers.

Workplace violence can include physical, emotional and verbal abuse, as well as sexual harassment. Employees are subjected to violence from co-workers, patients and visitors. Staff-to-patient abuse and elder abuse are risks as well.

Reduce your risk by preventing workplace violence

Following are ways Avecedo-Parker recommends protecting the safety of your staff and patients, as well as reducing your risk:

1. Be sure your comprehensive workplace violence policy and training are up to date. Review your employee training education, policies and procedures ensuring they reflect the realities of working in 2023. Do they address cyberbullying on communication tools like Slack? Do they include virtual threats on telehealth calls?  OSHA currently recommends workplace violence training as a best practice. Avecedo-Parker expects it will become a federal law in the future.
2. Establish procedures for recognizing and responding to signs of potential aggression. Train your staff members to identify, de-escalate and respond to a threat. When they witness aggression, be sure your team has bystander training to know how to respond. Have a system for reporting incidents and following up on any threats.
3. Consider a zero-tolerance policy. Many healthcare practices are developing zero-tolerance policies for workplace violence. This is a big first step in showing staff how serious this is. This can include having patients sign a zero-tolerance acceptance notice. 

Claim 2: Misdiagnosis in telehealth sessions

 

Telehealth has increased patient access to care and is also convenient for clinicians. It’s allowed clinicians to work in states beyond their licenses as part of interstate compacts.

Telehealth sessions also present new challenges for providers that come with the lack of physical interaction and contact. Forty-five percent of telehealth claims are for misdiagnosis of cancer, stroke and infection.

When making a diagnosis, a patient’s act of omission and miscommunication are risks to the patient’s health and to your practice’s liability. Factors such as patient age, pre-existing conditions, weight, mental health state and the patient’s ability to accurately describe their symptoms can all influence the accuracy of diagnosis.

 

Reduce your risk by preventing misdiagnosis

Following are ways Avecedo-Parker recommends protecting patients’ health and reducing your risk: 

1. Use best technology practices. Ensure you and your team have the technology you need to practice telehealth safely. This means using HIPAA-compliant video and messaging platforms. Ensure you’re using two-way video technology for a more accurate patient assessment. Conduct regular training sessions with your staff to ensure they stay current on the latest technology and protocols. Develop a protocol for when technology fails so clinicians can make accurate diagnoses.
2. Take accurate notes. To reduce the risk of misdiagnosis, providers should take careful notes, ask appropriate questions and consult with other professionals as needed.
3. Follow evidence-based protocols. Identify your clinical area’s common diagnoses and ensure practitioners follow evidence-based guidelines for diagnosis and treatment. Of course, be sure to follow the standard of practice for every diagnosis, even if that means requiring a patient to make a follow-up visit in person. For example, if someone has a urinary tract infection diagnosis requires a urine test. A telehealth visit for someone with symptoms of a UTI will still require a lab test. If a practitioner prescribes antibiotics without a test, this could lead to a misdiagnosis for treating the wrong infection.

 

Claim 3: Medication administration

 

Administering medications safely and efficiently requires experience and best practice protocols. 

Every healthcare professional knows the five rights of medication administration: right person, right dose, right route (administration), right time and right use. But ensuring your team keeps this in mind in every case – and takes no shortcuts – is crucial to reducing your risk. The consequences of not following the protocol became all too well known in the conviction of a Vanderbilt Hospital ICU nurse after a medical error that led to the death of her patient in May 2022.

 

Reduce your risk by preventing medication mistakes

To mitigate dangerous and costly medication mistakes, reinforce the five rights of medication administration. 

1. Establish a clear medication policy particular to your organization. Reinforce your medication administration policy by regularly educating your staff on the importance of adhering to the policy. Conduct ongoing training on safe medication practices and procedural guidance on how practitioners give the right medications. 
2. Encourage staff to report any mistakes or errors to supervisors immediately. It’s important to have systems in place for tracking adverse events related to medication errors. These systems should enable healthcare providers to identify trends or patterns in errors and take steps to prevent them. Additionally, organizations should consider implementing technologies such as barcode scanning or automated dispensing cabinets to reduce human error.

 

Claim 4: Slips and falls

 

Falls are a common medical risk, particularly in senior care facilities, which can lead to costly claims. About one in four adults in the U.S. (28 percent) age 65 and older report falling each year. This results in about 36 million falls each year. Staffing shortages have made the risk of falls even higher. This makes falls one of the most common practice claims. Healthcare providers must proactively assess patients’ risks for falls. Risk factors for falls include:

• Age
• Mobility issues
• Chronic conditions
• Medications that cause dizziness or balance issues
• Poor balance
• Impaired vision
• Cognitive impairment 

Reduce your risk by preventing falls

You can decrease the risk of falls by assessing patients’ risk factors and creating fall-prevention plans. This includes educating staff on fall prevention, implementing safety measures such as bed alarms or bed rails and following up with patients if a fall occurs. 

1. Get back to fall prevention training requirements. One of the most important prevention strategies is properly training staff to minimize fall risks. During the pandemic, Centers for Medicare & Medicaid Services (CMS) authorized skilled nursing facilities and states to request waivers for required training. Now that the public health emergency ended, it’s time to get back to meeting 75 hours of annual training. Training should include: teaching staff proper technique for transferring and mobilizing patients, assessing patient risk factors, providing appropriate assistive devices, and monitoring for any changes in the patient’s condition.
2. Train direct service staff to support patients with cognitive impairment. Patients with cognitive Alzheimer’s and dementia are at a higher risk of falling. You can proactively prevent falls by using chair and bed alarms and having more staff on hand during sundowning when patients tend to be more agitated.
3. Be sure your staff is rounding with a purpose. Routinely rounding to help residents with toileting and other needs is a key way to mitigate slips and falls. 

 

Claim 5: Working outside of scope of practice

 

Throughout the pandemic healthcare staff stepped up to meet the needs of patients, serving in a capacity that, for most, was unprecedented. For some, acute needs and staff shortages meant working beyond the scope of practice. Certified nursing assistants (CNAs) were left to fill the role of nurses. And nurses were responding to questions – based on deep knowledge – normally reserved for physicians or nurse practitioners.

Any misdiagnosis from a nurse practitioner or a physician that leads to harm is a risk. If that misdiagnosis comes from someone working out of practice scope, the risk is significantly higher.

Many nurses have years of knowledge based on experience. Still, making a diagnosis or calling in a prescription is outside the scope of their practice license. 

 

Reduce your risk by preventing your staff from working outside of scope of practice

Following are ways Avecedo-Parker recommends protecting patients’ health and reducing your risk: 

1. Develop protocols for responding to patient questions. Many healthcare workers, like experienced nurses, have vast knowledge beyond their scope of practice. However, following explicit protocols developed by a physician ensures they adhere to their scope of practice.
2. Educate staff on any changes in regulations or laws related to their scope or practice. Each state has regulations for every clinical license. Clinicians usually receive notice by email and mail when these changes occur. To ensure your practice stays compliant, regularly review state policies and procedures. 
3. Monitor and audit your staff. Conducting staff audits and reviews is a best practice that will reduce your claim risk. Having clearly-defined protocols and monitoring that care staff is following them ensures your practice provides high-quality care to patients and reduces the risks of a claim. Providing ongoing, documented training and guidance go a long way in creating a culture of safety in your organization. Documentation of all training sessions should be kept for legal purposes if a mistake does occur.

All healthcare workers have the potential of being reported in a claim and should consider obtaining personal malpractice insurance. This insurance provides financial protection and legal defense in case of malpractice allegations, which can help mitigate the financial and reputational risks associated with such claims. If a healthcare worker covered by CM&F Group does face a claim, they are encouraged to report it immediately, which allows for prompt resolution of the matter.

 

Gigi Acevedo-Parker, EJD, MSN, APN, RN, PMHNCNS-BC, HCRM, CPS, is HUB’s National Clinical Risk Management Leader, Risk Services Healthcare Vertical Lead, Risk Services Division and an advanced practice nurse with clinical specialty in psychiatry/behavioral health.