Referral Process Closed Claim Review with OMSNIC (episode 103)

07/07/2021 | Podcast

Here are the resources and transcript from episode 102 of our podcast Oral Surgery Admin’s Time Out Podcast: Practice Management Success Tips, which you can listen to below or find wherever you listen to podcasts. If you enjoy it, please subscribe, leave a 5-star review, and share it with your oral surgery colleagues.

Referrals hanging file

Episode Resources

OMSNIC offers additional resources for continued education on the importance of effective referral processes:

Episode Summary

Join OMSNIC’s Stephen Pavkovic and SOMSA’s Donna Germann as they discuss an OMSNIC closed claim that highlights the role of effective communication within the referral process, including the informed consent process and what to do when you have any questions about a referral’s treatment.

Episode Transcript

Jill Dunnam: Hi, and welcome to the Oral Surgery Admins Timeout: Practice Management Success Tips. In today’s episode, we have a risk manager from OMS National Insurance Company, Stephen Pavkovic and SOMSA member Donna Germann to discuss some important considerations for oral surgery practices. Donna will be hosting our podcast today.

Thanks for hosting. I’ll hand it over to you for introductions.

[00:00:38] Donna Germann: Thanks Jill. I’ve been a practice administrator for more than 25 years, and 17 of them have been in oral surgery. I’m currently working at Carolina Center for Oral and Facial Surgery in Charlotte, North Carolina, as the HR manager, helping to recruit talent and compliance for our 16 offices in North and South Carolina.

[00:01:01] Stephen Pavkovic: Good day. My name is Stephen Pavkovic. I’m the senior risk manager with OMSNIC based out of Chicago. Before beginning with OMSNIC in 2018, I worked as an operating room nurse and a manager. I also earned advanced degrees in law and public health. On the legal side, I’ve worked as a medical malpractice defense attorney here in Cook County, Illinois, which has been called a judicial hell hole. That was a great experience. I’ve also done some transaction in health law practices for academic medical centers.

I bring this experience to OMSNIC to help the company and also our insurers identify patient safety and loss control opportunities, and really appreciate the opportunity to use what I call my entire brain and experience for the benefit of our insureds and ultimately the patients that we all serve.

[00:01:50] Donna Germann: Thank you, Stephen. What’s the topic of today’s discussion?

[00:01:54] Stephen Pavkovic: Yeah, today, we’ve learned from the SOMSA members that they really appreciate the patient safety lessons learned through our closed claims summaries. And today we’ll discuss a closed claim summary that highlights the role of effective communication within the referral process

One of our take-home messages today, something we’d like you to think about as you reflect on this recording, is that if there are any questions at any time about any referral, the safest course from a patient safety point of view, the safest course from a risk management or loss prevention point of view, is actually to delay and, uh, resolve those questions before initiating treatment.

[00:02:36] Before I start, I do need to share our disclaimer. As a reminder today, we’re talking about general risk management and patient safety principles related to the referral process. This information should not be construed as providing legal, medical, or professional advice of any form whatsoever. It is your responsibility to evaluate the usefulness of this information.

Because federal, state, and local laws vary by location, nothing in this discussion is intended to serve as legal advice or to establish any standard of care. Legal advice, as always, if desired, should be sought from competent counsel in your state.

[00:03:15] Donna, as I mentioned, this closed claim summary relates to the referral process. From your practice perspective, what can you share about your experience with the referrals?

[00:03:26] Donna Germann: Sure. Approximately 75  % of our patients come from referrals. Our practice works to maintain open communication with our referring providers and their staff. The great majority of referrals are received directly from the referring provider before the patient presents.

That said, I’m eager to compare my experiences with OMSNIC’s closed claim summary to see how our practice and other SOMSA members might find improvement opportunities for managing the patient referral process.

[00:04:01] Stephen Pavkovic: Yes. Very good to hear that background and I’m sure that’s a similar experience for many of the SOMSA members.

This closed claim summary involves a 33-year-old patient, male, who presented to his general dentist with diffuse generalized mouth and tooth pain in the setting of years of dental neglect—probably a patient you see on an unfortunately too regular basis.

The general dentist’s office staff called the OMS office staff—and in this situation, that OMS is an OMSNIC insured—to schedule an appointment. There was no additional documentation provided by the general dentist to the OMS office to indicate the purpose of the appointment.

Based upon the phone call, the OMS office staff scheduled the patient for a full extraction of all remaining teeth and noted in the scheduling notes that the patient would bring a referral letter and dental imaging to the appointment.

[00:04:56] Fast forward to the day of the appointment, and the OMS staff noted in the dental records and the medical records that the patient had not presented the referral letter or any imaging. The OMS office staff or the OMS himself did not attempt to contact the referring dentist to confirm the treatment plan.

Rather, the OMS consented the patient, uh, conducted a consultation and then consented the patient for a “full mouth extraction with IV sedation,” and this was on the same day of the patient’s presentation to the office.

Donna, based on the snapshot of facts we have at this point, what are your initial thoughts here about managing a patient who presents without an appropriate referral information or imaging?

[00:05:43] Donna Germann: If a patient presents without a referral letter, our office would delay all care until questions related to the referral were answered. Some of those specific steps include

  • calling the referring dentist to clarify the purpose of the appointment,
  • offer to reschedule the appointment, if the referring provider could not be reached, or
  • complete a consultation appointment only.

Did any of these steps occur in the claim?

[00:06:10] Stephen Pavkovic: The fact that we’re talking about it, you can anticipate not, and these are great steps to really keep the focus on a patient themselves and had any of those steps you mentioned—such as contacting the referring dentist, rescheduling, or just completing the consultation because you have the patient there without the other interventions—may have actually resulted in a different outcome for this patient and also prevented the lawsuit being filed.

Let’s return to the facts of the case. As I said, none of those occurred. The clinician, after consenting the patient for the full mouth extraction, noted in the clinical documentation that the patient had no questions about the procedure and that the patient was “eager” for the extractions to be completed.

Fortunately, the procedure itself involved the extraction of the eight remaining teeth and 12 retained root tips. That was completed without any reported anesthetic or surgical complications, and the patient was discharged with an escort to home. Normal OMS follow-up after the extractions was planned.

That evening, the patient’s wife contacted the OMS and stated, “What have you done to my husband? You were only supposed to have taken out his top teeth.”

[00:07:26] The notes indicate that the patient’s wife was very upset about this, and almost a level of very demanding and yelling on the phone, which was concerning for the OMS staff. The OMS replied that the patient had requested the full mouth extraction and that was the procedure that was performed at the patient’s request.

However, the wife said that she had the referral letter in front of her from the dentist, and she stated that the procedure was for the “extraction of the upper teeth” only.

The OMS asked why, if the caller had the letter in front of her, she did not provide the letter to the office staff earlier in the day or the patient themselves when they presented in the office.

The wife said that her husband had tried to get the letter to the office staff when he first entered the office, but the office staff refused to accept the letter.

During the course of the litigation, interviews with the office staff from the OMS were conducted and no one from the office staff recalls that the patient had attempted to present the letter.

Donna, this is a little more, not specific to the case itself, but in general, how would your practice manage a caller or a family member calling on behalf of a patient who’s very upset, or a caller who had concerns about the care that had been provided.

[00:08:44] Donna Germann: First, we would confirm that the call did not involve a medical emergency. If the call was more related to patient satisfaction, as in the closed claim, we would have an OMS speak with the patient directly to prepare our response.

Given the type of patient complaint in the closed claims, our practice would call OMSNIC to report this as an event that may later turn into a claim.

[00:09:10] Stephen Pavkovic: Yeah, those are some appropriate steps here and really show a focus on providing good patient care and good customer service.

Regarding the contact to OMSNIC, there are a number of clinical incidents which OMSNIC requests that our policy holders contact us about. These incidents are identified on our website at OMSNIC.com, and specifically in this topic include any incidents, adverse events, or patient complaints that may later turn into a claim, such as this type of call.

I’m aware that other insurance carriers have similar guidelines for when to contact the carrier about a clinical scenario, and we recommend all providers be aware of those and also the methods to contact their insurance carrier.

[00:09:55] Uh, ultimately the patient did file a lawsuit claiming damages for the additional extractions. And we’ll be talking about some of the allegations specifically in that lawsuit as we continue our discussions here.

[00:10:08] Donna Germann: I’m surprised that the patient filed a lawsuit since the patient sounds like many we all too frequently see in our practices. It was likely only a matter of time until the mandibular teeth would need to have been extracted. What were the specific allegations against the OMS?

[00:10:27] Stephen Pavkovic: Yeah. In this case, the allegations follow the classic traditional elements of a medical malpractice claim. There’s four essential elements for that.

One is that there is a duty owed to the patient, professional duty. The second is that duty was breached. The third is the breaching of that duty caused, and the fourth element is damages. So duty, breach, causation, and damages. Those are the four elements and that’s exactly what, uh, was pled in this case.

Here, a little more specific, the allegations were that the mandibular teeth were negligently extracted by the OMS, that these extractions caused the patient additional pain and suffering, future pain and suffering, and more expensive future treatments.

[00:11:15] During the discovery phase of the lawsuit–or one of the pre-trial stages of the lawsuit, where the parties exchange information related to the allegations of the lawsuit–and the discovery phase usually has two elements. I’m speaking generally here. One is the written stage where, uh, questions are exchanged back and forth. And the second is the oral discovery or testimony related to depositions, et cetera.

So in discovery, the office staff recalled

  • that the patient did not offer a referral letter on the day of surgery,
  • that the office staff overheard the OMS discussing the procedure with the patient, and
  • that they confirm the procedure themselves, being full mouth extraction. With the patient during the pre- procedure timeout.

[00:12:04] Also during the discovery stage, the referring dentist produced the referral letter that confirmed only the maxillary teeth were to be extracted. However, there was no record or documentation that the referring dentists had sent the referral letter to the OMS before the patient’s appointment or treatment, which as you may recall, was on the same day.

During the oral discovery phase, the patient was deposed and he stated that

  • he took poor care of his teeth in the past, but that he was committed to making changes required to protect his bottom teeth;
  • that, while he was aware that he may have needed to have had his bottom teeth extracted in the future, that the bottom teeth were relatively healthy and pain-free as compared to the upper teeth; and
  • that he did not consent to have the mandibular teeth extracted.

That the patient consent element did become a significant portion regarding the resolution of this matter.

Also in deposition, the referring dentist testified that the patient was committed to protecting his bottom teeth after healing from the maxillary extractions.

[00:13:12] Donna Germann: Stephen, you mentioned that the patient signed a consent for a “full mouth extraction with IV sedation” before the extractions. How could the patient later allege in a lawsuit and testify in his deposition that he did not consent to having the remaining mandibular teeth extracted?

[00:13:30] Stephen Pavkovic: Sure, this is a very good question. And also one of the other key learning points about this claim, the role of informed consent.

Yes, it’s correct. The patient signed consent form and was–use some air quotes here– consented for a full mouth extraction. However, at his deposition, the patient testified that

  • he was in pain at the time he presented in the OMS office and not thinking clearly,
  • that he did not know what “full mouth” meant, and
  • that even if he knew what “full mouth” meant that he thought the OMS or the referring dentist had a new treatment plan or plans for the mandibular teeth that was not shared with the patient, but that ultimately they knew best.

[00:14:17] Essentially the patient testified that he did not know what he was signing or what it meant ultimately to his lower teeth for what he was signing.

As we’re aware, informed consent is a process and more than just a signature on a consent form. OMSNIC has a number of resources related to the informed consent process. And one of those is on our YouTube channel, which is an approximately four-minute patient safety minute on the informed consent process. It’s a quick snapshot outline.

The three parts of the informed consent process are:

  • first a discussion between the treating provider and patient.
    • In this discussion, the focus is on the diagnosis, the proposed treatments, the benefits of the proposed treatments, the risks, the alternatives to the proposed treatments. Also the risks, benefits, and alternatives to delaying treatment, which is considered as one of those alternatives.
  • A signed consent form is the second part that reinforces and memorializes this discussion.
    • As many of you are aware, OMSNIC has a library of informed consent forms, with many forms available in Spanish, that can be downloaded and customized for the specific needs of each practice, and then also more specifically, the specific needs of patient and clinical scenario.
  • The third part of the informed consent process is actually clinical documentation in the patient’s records.
    • The documentation topics includes what was discussed with the patient, visual aids–if they were used–such as educational videos or 3-D models, et cetera.

Quotes from the patient can be very helpful and questions and answers from the patients can also be very helpful because when they are entered contemporaneously, they provide insight to the patient’s thought process as the information is being provided.

[00:16:09] So for example, in our claim that we’re discussing, had the patient said, “So you mean I’ll have no teeth on the bottom?” That would be a statement, if that was entered contemporaneously and had the patient said that, that would have been a supportive of the fact that the patient understood the impact of having a full mouth extraction.

In this case, there was not that type of clinical documentation to summarize the entire process, and with those gaps and just the patient’s discussion and consent form for the full mouth extraction were significant challenges for the defense.

Additional challenges, where the testimony from the referring dentist and also the patient themselves about planning for the restoration and saving of the bottom teeth.

[00:17:01] Ultimately multiple challenges here, as I mentioned, and it really came down to a few key points for the defense.

  • One was the absence of coordinated care between the referring dentist and the OMS. This is demonstrated by the missing referral letter, not that the letter in and of itself is proof that the care was coordinated. However, the letter was absent and then there was no other documentation and the testimony revealed there was no other attempts to communicate between the referring dentist and the OMS for the treatment plan.
  • Also, there was no clinical documentation from the OMS to demonstrate and contemporaneously memorialize that the patient participated in the informed consent process. And as I mentioned, this is where some of the quotes from the patient or some of the types of questions that the patient asked could have been very helpful to illustrate the patient’s understanding of the proposed treatment.

[00:18:01] Based upon these challenges, the claim was settled before trial, given what was anticipated to be significant challenges for the defense before a jury. Some of the specific items that really did drive–and this is a little bit of a summary here–was that

  • one, the dentist referral letter accurately identified the intended procedures,
  • that the OMS prepared a treatment plan without any direct information from the referring general dentist, and
  • that the patient signed a consent form, which included somewhat vague terms—like “full mouth extraction”—and our experts at OMSNIC determined that this level of “full mouth extraction” may have been beyond the comprehension level of this patient, given his history of dental neglect and, as the patient testified, with acute dental pain.

[00:18:49] Donna Germann: I can certainly see the lack of direct communication here between the referring dentist and the OMS led to the outcome. What information does OMSNIC recommend that a clinical referral include?

[00:19:02] Stephen Pavkovic: Yeah, there’s very good question. And we do have some key considerations which can be helpful to establish a coordinated patient care and also a safe referral process.

This information contained in the referral letter is that it’s timely, legible, accurate, informative, and responsive. These are the factors that should be considered for referrals, both received by your practice and those that are sent to other providers. I will mention that there is some overlap in these topics and really putting them together, keeping the focus on coordinated care is the point of the referral process.

Timeliness and legibility are generally self-explanatory. However, these can be factors in cases involving failure to treat claims or failure to diagnose, such as those with infections or diagnosis.

Legibility is less and less of a problem in the world of electronic medical records. Although I will say that many offices and practices may still have some handwritten documentation and some of those forms in place for what might otherwise be considered a very modern, electronic medical record based dental practice.

[00:20:22] And on a personal example, I’ll share that my 17-year-old son successfully had his upper third molars taken out and he’s at a very modern practice, nice, shiny, bright, new, lots of technology. However he did receive a handwritten referral note for the OMS extractions. There were no issues with that. However, I was quite surprised, and this is the kind of thing that, speaking with some practitioners, that many offices and many practices still may have some vestiges of handwritten documentation in place and something to think about, it’s really that legibility.

[00:20:59] Another issue that can be a challenge with clinical documentation referrals is actually including and incorporating those referrals letters into the EMR. The important part to do that is that these referral letters become part of the treatment planning and clinical decisions. Donna, when your practice receives a handwritten referral or other types of forms related to patient care, how are these managed with your EMR?

[00:21:31] Donna Germann: Well, approximately 50 % of our referrals are handwritten and 25 % of them are provided on the day of the initial consultation by the patient.
All handwritten referrals brought in by patients are scanned into our EMR by the front desk staff or the manager.

[00:21:48] Stephen Pavkovic: Yeah. It’s important to get that information into the practice and, Donna, do you believe that the referrals are one of the primary areas where you still have handwritten information?

[00:21:58] Donna Germann: Yes. Most of the time, that’s still happening at the front desk, so they’re handwriting at the referring doctor’s office and sending it along.

[00:22:07] Stephen Pavkovic: Okay. It’s interesting, Donna, do you find in your practice that the handwritten referrals are the primary area of handwritten materials that are coming in, even though your office does use an EMR?

[00:22:20] Donna Germann: Yes, because I think the referral offices are still handwriting them at the front desk and then sending them over to the OMS office, either fax or email or sending them with a patient. But yeah, they’re still handwritten.

[00:22:35] Stephen Pavkovic: Thanks for sharing that. I think that could be a great opportunity to improve care coordination across the board and also something to think about for really driving as a good risk management practice.

As you’re aware, many times that referral letter is what drives the treatment plan for the OMS. So with the high percentage of your business focused on referrals, this really is a critical step in the process. Thank you for sharing that.

You know, some of the other things involved in referrals, as we talked about, timeliness and legibility, some of the other things include accuracy, informativeness, responsiveness of the referral. While there’s overlap on these, you know, additional factors collectively the focus is really on assisting to deliver care that is focused on patient safety and providing the treating doctors with the information that is required to deliver the appropriate patient care.

Accurate and informative referrals may become particularly important as we think about it in a pediatric patients, medically complex patients, or patients with staged treatment plans, such as the case for the patient in our closed claim.

[00:23:50] One risk management strategy related to referrals is to establish a referral process for your practice. And once again, here, we’re talking about both referrals which are received, at the same time, though, there’s an opportunity also to think about referrals which are sent from your practice and then to share those practice expectations for the information and format with the referring providers.

Donna, has your practice taken any proactive steps to assist with the overall referral accuracy?

[00:24:23] Donna Germann: Yes. Our practice is using several strategies to improve the referral accuracy. Some of them include

  • frequent calls with our referral base to establish our practice expectations–this is a valuable step, especially with new referring providers, and
  • promptly contacting any referral office when there are questions about any element of a referral.

These steps help our office to promote an efficient referral process and prevent care delays.

[00:24:54] Stephen Pavkovic: Yeah, that’s correct. That’s the type of communication strategies and plans that OMSNIC means when with the term “responsive referrals”: proactively discussing communication strategies and your expectations as to what should be included on a referral with the providers. And this is a process which actually can assist in creating a referral process that’s responsive to your patient needs. In addition, you know, there are some benefits also to your scheduling. I’m sure having unexpected delays during your day could be a great challenge for many practices.

Collectively, looking at these factors related to the referral process is a solid risk management strategy. And really the take home message, as we talked about, is that any time a question arises about non-emergent treatment, it’s important to know that treatment can be postponed until such time as the communication can occur between the doctors and any questions related to the referral process can be answered and resolved.

[00:25:57] Back in our claim, our analysts determined that an appropriate referral in this claim could have likely prevented the lawsuit. Were a referral to have been available for this claim, you could anticipate that an informative referral would have included the treatment and imaging completed to date; the future treatment plans, which would have mentioned the restoration and attempts to maintain the bottom teeth; and also then the goals for care with this patient.

Collectively appropriate letter here, and this is somewhat of a crystal ball approach, but however, it may have prevented extraction of the bottom teeth and provided the patient with the goals of care, which were to help them salvage the remaining mandibular teeth.

[00:26:45] Donna Germann: With the benefit of hindsight, is there one element of the referral process that may have promoted safe patient care and prevented this claim?

[00:26:54] Stephen Pavkovic: Likely? Yes. And as I mentioned, we’re somewhere in the world of hypotheticals and speculation here, but in this claim, the OMS treated the patient without adequate information about the basis for the referral, including the care that was completed to date, the planned care as the next stage, and the overall goals of care for this patient, and the OMS’s is role in that care plan.

Performing the extractions without knowledge, this type of information, which would routinely be included on a referral, was determined by experts for the OMS to be a basis for settling the claim, as I mentioned, we anticipated that these would be challenges before a jury were this case to have gone to trial.

The experts in this case also were questioning the OMS, that the OMS

    • did not attempt to contact the referring dentist about the treatment plan,
    • proceeded with non-emergent treatment without confirming the goals of care,
    • did not document details of the patient’s participation in the informed consent process, and
    • did not document the information relied upon from the patient and other sources for the OMS treatment options.

Wrapping up today’s discussion, I wanted to remind our listeners that this discussion relates to general risk management and patient safety principles with and related to the referral process, and that this information may not apply to every clinical scenario or practice.

[00:28:29] If any of the SOMSA members and listeners today with OMSNIC-insured practices have a specific question about the referral process or other risk management topics, please contact the OMSNIC risk management team at 1-800-522-6670.

Donna, thank you very much for the discussion today. I appreciated the opportunity to speak with your SOMSA members.

[00:28:56] Donna Germann: Thank you, Stephen.

[00:29:04] Jill Dunnam: Wow, thank you so much for sharing such an interesting and devastating case. The situation you reviewed today was so terrible for the patient and the oral surgeon. So great for all of us to know ways we can prevent this kind of situation in our practices. In my experience, Donna’s practice is a fantastic group of surgeons and OMS National Insurance Company does a great job of taking care of their insured practices and also has been a great supporter of the Society of OMS Administrators.

Thank you all for listening today. We appreciate your time.

Referrals by Nick Youngson CC BY-SA 3.0 Alpha Stock Images