Physician FAQs

You’ve got questions; we’ve got answers.

Have a question that we haven’t answered here? Don’t hesitate to get in touch.

Claims

  • A claim is a demand to be compensated for an alleged injury. The most obvious example is when you are being sued. You may encounter a situation with a patient who is unhappy with an outcome. This is not a claim until there is a demand for compensation or formal proceedings based on alleged medical negligence are initiated. We do encourage you to call our Claims Advice Hotline at 1-800-640-6504 and discuss the situation.

  • If you have been contacted in regard to a lawsuit, or you suspect that you may be contacted in the near future, it is important to contact us immediately so we can proceed in your defense. Call our Claims Advice Hotline at 1-800-640-6504, to discuss your situation with a professional claim representative.

    DO NOT attempt to contact the patient or the patient's attorney to discuss the lawsuit or any other paperwork you may receive. Avoid the temptation to talk with your friends and colleagues about the lawsuit. It is important that your insurance provider is the first person with whom you discuss the details of the case. You should also gather and secure the patient's records immediately.

  • As a busy healthcare professional, it is likely you may be subpoenaed at some time during your career to provide medical records or give a deposition concerning your care of a patient. In many instances this is an everyday occurrence and unrelated to criticisms regarding your care and treatment. For example, your patient may be involved in some type of personal injury or workers' compensation accident where your records or testimony as a treating physician are necessary to prosecute or defend the personal injury lawsuit or workers' compensation proceeding. Keep in mind that state laws vary, but in many jurisdictions the attorneys defending personal injury or workers’ compensation claims are not permitted to discuss the patient’s case with you absent written authorization from the patient. Their only means of getting information regarding your care and treatment is a formal deposition proceeding with all parties to the suit present. If you are comfortable that is the case with the subpoena and are experienced in giving depositions, it is not necessary that you contact our Claims Advice Hotline. 

    If, however, you are not certain about the purpose for the records or deposition subpoena, or have concern that either the patient or other parties already named in the lawsuit could be attempting to claim some wrongdoing on your part, you should contact us immediately so we can proceed in your defense, if necessary. Call our Claims Advice Hotline, 1-800-640-6504, to discuss your situation with a professional claim representative. Again, treat the subpoena just as you would any formal claim against you. DO NOT attempt to contact the patient or the patient’s attorney to discuss the subpoena or any other paperwork you may receive.

  • Professional Solutions pays your defense costs up to $25,000 total for all state licensing board investigations commenced during a policy period.

  • A licensing board investigation is any investigation by your state licensing board. If the board contacts you, and it is not a part of your standard license renewal, then it is an investigation.

  • You should report it to Professional Solutions immediately. Even if you aren't sure whether the situation is an actual claim or licensing-board investigation, call the Claims Advice Hotline at 1-800-640-6504. Our professional claim representatives will help you determine the best course of action. We will help you use your coverage to its fullest advantage or point you to resources you may not have been aware you had.

    The licensing board is there to protect the consumer – not the doctor. You need the experience of an attorney familiar with licensing board investigations. Even seemingly innocuous questions can be fraught with pitfalls for a doctor unfamiliar with licensing-board investigations.

  • Even if you aren't sure whether the situation is an actual claim or licensing board investigation, call the PSIC Claims Advice Hotline at 1-800-640-6504. Talk to one of our professional claim representatives and let him or her help you determine the best course of action. We will help you use your coverage to its fullest advantage or point you to resources you may not have been aware you had.

  • Any act that breaches your professional practice or standards may prompt an action. Common occurrences include such conduct as incompetent practices, medication errors, documentation errors, practicing outside the scope of your license and/or certification, patient complaints and failure to timely renew your professional license. Our current coverage provides for expenses incurred while defending your interests in disciplinary actions. We understand the importance of your license to your livelihood and will help you to protect it.

  • Timing is crucial. When you receive a claim or are under investigation by your licensing board, you often have a limited time to respond — normally between 14 and 30 days. The sooner you report the situation to us, the sooner our defense team can determine the proper course of action. Your attorney needs ample time to help you craft the best defense. Any delay in reporting could impair your defense by limiting the available time for response.

  • Absolutely! Some insurance companies say they will not settle a case without your consent--however, if you don’t provide your consent, their policy may allow for arbitration to determine if you are withholding consent unreasonably. An arbiter’s finding that consent is being unreasonably withheld could authorize the company to settle the claim without your approval. At PSIC, no case is ever settled without your written consent to settle - giving you full voice in settlement issues since it’s your reputation and good name on the line.

  • A deposition is testimony given under oath before a court reporter, but they usually take place in an attorney's office, not the courtroom. Depositions are important in the preparation of a case for trial and generally permit questions that are broader than what is permissible during the actual trial. Depositions can be used to impeach your credibility if you later deviate from prior statements. They are used to discover facts of the case and to uncover additional witnesses. Depositions are also used to narrow the issues of the case. Failing to appear for a deposition potentially subjects you to being held in contempt of court. Always consider exercising your right to legal counsel before providing deposition testimony.

  • Contact the Pro Claims Advice Hotline for guidance as soon as possible. Make no admissions of liability. Always attempt to discuss the situation with PSIC before meeting with hospital risk management.

Risk Management

  • There are actually lots of rules regarding retention of records. When it comes to records retention, unfortunately, there is not an easy “one size fits all” answer to this question.  The answer depends on the circumstances surrounding the patient and the practice location. 

    Common questions/scenarios to consider:

    • If the patient is or was a minor, the records should be retained until the minor patient reaches the age of majority, then a specified time period after that date. 
      • What is the age of majority in your state?  How long the records must be kept after reaching the age of majority?  Check with your state regulation.  Generally use the statute of limitations.
    • If the patient is or was incompetent at the time of treatment, what are the rules in this situation? 
      • Some states require the records to be retained until after the death of the patient. Does your state define this situation; however, if patient was receiving Medicare/Medicaid those rules will apply as well as majority age
    • If the patient is now deceased, how long should the records be retained after the date of death? Generally use the same Medicare/Medicaid rules of 6 years
    • If the patient was covered by Medicare or Medicaid how long must the records must be kept? 
      • What is the particular rule in your state?  Generally, it is for at least six years after reimbursement
    • If there is a dispute involving services, does this affect the retention period? 
      • Generally, the records should be kept until the dispute is resolved then the specific length of time based on state code.

    The best resource for the length of retention in each situation is your association or legal counsel to get their input on state statutory code and statute of limitations.

  • You are allowed to alert another physician within your practice with whom you may share patients or who provides coverage during your off time. However, warning physicians outside of your practice would violate the patient’s confidentiality. We suggest you meet with the patient to discuss your concerns regarding what you perceive to be a chemical dependency. During this meeting you might suggest professional help and outline conditions for continuing your professional care. Should the patient refuse a meeting or not accept the conditions proposed, you may want to consider terminating the physician-patient relationship. A good way to prevent cases from reaching this stage is to develop a policy statement that explains the kind and number of pills that will be dispensed at any one time, how a request for “emergency” narcotics will be dealt with, and how renewing a prescription for narcotics will be handled. This information should be provided to new patients and discussed with each new patient on his/her initial visit. Clearly explaining the practice’s policies and procedures before prescribing narcotics can help avoid misunderstanding and drug-seeking behavior from patients.

  • When leaving a message, your message should only be your name and the office number and only if the patient has given you permission to call them at work. Patients should be made aware that phone messages at work may not be confidential. If the patient wants more detailed messages left at work, get permission in writing and clarify how much information to reveal in the messages. The amount of information to be left should be documented in the medical record.

    In situations where a patient has requested the physician communicate with him/her by alternative means or at an alternative location, the physician must accommodate that request, if reasonable. For example, HIPAA considers a request to receive mail from the physician at a post office box rather than at home, or to receive calls at the office rather than at home as reasonable requests, absent extenuating circumstances. Document your records as to who left the message (name/position; time of call, what information was left, and reason for the call). Do not use the acronym LMOM.

  • Not necessarily. In fact, many physicians will reduce a patient’s bill in an effort to enhance customer satisfaction. However, it is important you talk first with one of our claims representatives. Reducing a patient’s bill does not mean the patient will not later file a claim against you.

  • Document your recommendations and the patient's noncompliance. Advise the patient of the potential consequences their noncompliance or refusal may cause and document your discussion. Confirm the patient's noncompliance, your subsequent discussion, and the potential consequences in a letter to the patient sent certified mail, return receipt requested. Send a copy of the letter by regular mail as well. Consider withdrawing from the patient's care, but first review the language of any managed-care contracts that may apply to the situation and seek guidance from PSIC. If you practice in a group setting, it may be necessary to withdraw on behalf of others in the group as well as the practice.

  • Some state boards do have specific regulations governing the manner in which medical records are destroyed. Where no specific regulations exist, the best way to dispose of records is by burning, shredding or similar protective measures. Don’t burn x-rays – they contain a toxic chemical. If arrangements are made with third parties or entities for the destruction of patient records, a written agreement should be obtained clearly obligating the entity to safeguard confidentiality as well as indemnifying and holding harmless you and your practice from any breach of confidentiality for which they are responsible. Some state regulations require you to witness records destruction that is performed by a third party. Before destroying records, confirm the timeframes of the specific record retention laws in the state in which you practice. Do not “single out” specific records for destruction outside of the standard office operating procedure for records destruction, and record the time, date and circumstance of the destruction for future reference.

    Office Protocols should clearly define the steps before destruction such as:

    • patient criteria based on statutory code and statute of limitations has been reviewed and met
    • patient has been given the opportunity to obtain the information, if feasible, or have it sent to another provider
    • patient records to be destroyed have been entered into a master log (which is maintained indefinitely) listing the destroyed records and includes such information as:
      • the patient’s name
      • date of birth
      • last date of service
      • date of destruction
    • name of Company or individual performing destruction
      • If a company is hired to destroy records, the company should sign a confidentiality agreement and provide certification of the destruction
    • method of destruction
    • signature of individual witnessing destruction

  • Maintain the original paper records for at least 30 days after they are scanned. During this time, randomly review the scanned charts to make sure they all scanned appropriately.

    • Visual inspection of each scanned document image ensuring the image is complete (the entire document has been captured).
      • Scanned image must be clear, easily read and usable
      • Not skewed/shows entire image of document being scanned/be of good quality
    • Comparison between scanned records and the original paper documents confirming accuracy.
    • Validation of the number of original paper documents is compared to the number of scanned records to make certain every document was scanned.
    • Check for two sided pages
    • Blank pages are noted as “Intentionally left blank”
      • If a good, clear scan is not obtainable, the record should be noted as such being the “best possible scan”
    • Quality controls in the manner of a periodic audit by the IT department or practice manager is done when scanning projects are underway to check for critical errors such as
      • Document scanned to wrong chart
      • Document is not complete/clear/readable
      • Document is missing patient identifiers
      • Document is missing pages with no explanation or identifying what was excluded

  • Yes, if the patient has requested an interpreter, whether it is due to a disability or English as a second language, it is necessary you cover the cost for that service. You cannot refer them to another provider based on this request or request they bring a friend or family member to interpret. Review the Americans with Disabilities Act (ADA): What Dental Professionals and Staff Need to Know.

  • Retention and access to medical records is assumed by the new corporate entity/practice. The written purchase agreement should clearly state a record retention policy that has been agreed upon by both parties.

  • Information regarding sexually transmitted diseases, HIV/AIDS, abuse of drugs or alcohol, and mental health should never be faxed. Likewise, it is recommended physicians avoid routinely faxing patient information to insurance companies, attorneys or other non-health care entities if the information can be effectively sent by mail or messenger service. The best practice is to only fax patient information for an immediate patient-care encounter.

    If it is necessary to fax patient information, it is recommended the intended receiver be called just prior to sending the fax to ensure the information is received and promptly removed from the fax machine. Some tips to consider:

    Pre-programmed numbers should be confirmed at least every six months, if not sooner. To be HIPAA compliant, a coversheet is required which details:

    • The sender’s name (individual and facility), telephone number and fax number
    • Date and time of transmission
    • Number of pages being sent including the coversheet
    • Intended recipient’s name, facility, telephone and fax numbers
    • Name and number to call to report a transmittal problem or to inform of a misdirected fax
    • A HIPAA confidentiality statement
    • DO NOT include any PHI on the coversheet

    A confirmation sheet, printed by the fax machine, should be included in the patient’s medical records with a note as to the information faxed.

    We also recommend that on the cover sheet include instructions to destroy the information should it accidentally be sent to the wrong number along with the request that anyone incorrectly receiving the fax call the sender and notify him or her this has occurred. To avoid sending information to a wrong number, we suggest you take a moment to confirm the correct number has been entered prior to pressing the “send” button. If it is suspected a fax was sent to the wrong number, retrieve the number from the machine’s internal logging system and fax a request to destroy the information.

  • Insurance coverage does not dictate clinical needs or decisions. Physicians must advocate for the care or treatment warranted by a patient’s condition. Physicians should be aware of the appeal and grievance processes and if necessary, make an appeal or facilitate an appeal by the patient or employer. Based on the outcome of the advocacy efforts, the physician should obtain the patient’s consent for treatment, or refusal of treatment. The patient should be made aware that in instances in which the insurer refuses to grant payment, the physician is not refusing to do the procedure/treatment. However, an alternative method of payment will need to be agreed upon. If appropriate, the physician may want to discuss reasonable alternatives to a rejected treatment plan with the patient and his/her family members. The physician also may want to assist the patient with alternative payment options. Most importantly, all discussions, appeals and decisions should be carefully and thoroughly documented in the patient’s medical record.

  • Yes, when a physician-patient relationship is not a good match, the physician should assist the patient in finding a new provider within the managed-care organization (MCO). When working with a MCO, physicians agree to accept its policies; therefore, it is a good idea to check with the MCO regarding its transfer policy. The physician should also ensure the transfer of care does not occur until the new provider is in place. All conversations with the patient, the MCO, and the new provider must be carefully documented. Lastly, transfer copies of the patient’s medical records in a timely manner. As always, physicians are encouraged to contact PSIC's Risk Management Team if they need assistance terminating their relationship with a patient.

  • If the minor has the authority to consent to treatment (check your state’s laws) and insists on confidentiality, then the minor is generally (but not always) financially responsible for the cost of the treatment. Be sure to check state laws regarding financial responsibility of minors. Frequently, the minor will be covered for care under a parent’s healthcare insurance. However, if a minor requests that the services (e.g., birth control, pregnancy, etc.) be paid by a parent’s healthcare policy, the minor must be advised, in advance, that the parent will be informed of the care and treatment because the insurance provider will send a copy of the bill to the parent regarding the service provided. Document your conversation with the minor patient.

  • Yes, but only leave your name and request the patient return your call. Be sure to document in the medical record you left a message. The documentation should include the instructions left such as, “asked patient to return call” and include the name and credentials of the staff member who left the message. The documentation in the patient’s record should include a brief summary of why the call was placed. For example: “Called patient to advise Dr. G has reviewed the test results and levels are within normal range. Dr. G said to continue medication as he explained and follow up as planned.” This way, when the patient returns the call, if that staff member is out of the office, the individual filling in for can provide the information to the patient as to why the call made.

  • No. X-ray films are the property of the originating physician or radiology group. By law, the patient may access his or her films and upon request, be furnished a copy. However, original films should never be released. The patient may be charged the cost of reproducing x-ray films. Federal guidelines from HIPAA address what can be charged and the allotted time frame for fulfilling the request, review www.hhs.gov for current information.

  • No. The patient can assert that the medical advice was purely for some aspect of treatment, such as surgery or physical therapy, but not all care and treatment. Always document and record in the case of a patient not following medical advice, and send a letter to the patient confirming his or her forfeiture of care and the potential consequences of those actions. Ask the patient to reconsider, but do not deny the patient access to ongoing care. Consider terminating the physician-patient relationship. Depending on the circumstances, seek legal guidance before taking such action.

Other

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