Patients

In Honor of Complaint Management

Treating complaints with prompt action can lead to patients feeling more positive about their experience and offer your practice valuable lessons.


Good reviews by patients, whether online, on a satisfaction survey, or when talking to someone new to their neighborhood, promote the growth and success of a medical practice. Just as important are your patients’ stories of a problem they experienced that you and your staff immediately and fairly addressed, especially if those patients are still your patients.

If you ignore or superficially manage complaints, your former patients will tell only that part of the story, leaving out the part about your quality medical care. You and your staff may also miss out on valuable lessons and opportunities for care quality improvement. Responding appropriately to patient complaints may also help physicians, advanced health care professionals, and practices stave off medical professional liability lawsuits (“MPL”) arising out of these complaints.

The Complaint

The patient made an appointment with an ear, nose, and throat specialist, Dr. Enteman, for excess ear wax. While this was the patient’s first appointment with Dr. Enteman, she had seen other physicians for wax removal in the past and assumed Dr. Enteman would perform the same procedure.

While examining the patient’s ear canal, Dr. Enteman identified a small benign cyst and performed a more in-depth procedure than cerumen removal. Dr. Enteman did not tell the patient about the cyst or obtain her informed consent for cyst removal. Based on prior experience with other patients, he assumed the patient would just agree. He then documented his examination, rationale, and the procedure.

When the patient received a bill for $100 more than expected, she called the practice and demanded that the practice take the cyst removal off the bill. Dr. Enteman and the practice manager were highly concerned and discussed the situation.

The No Surprise Billing Lesson

Dr. Enteman and the practice manager had heard of the new federal No Surprises Act but weren’t sure if this fell under the Act or how to comply if it did. They called the hotline and learned that the Act and its related rules went into effect January 1, 2022, and apply to all physicians, other licensed health care professionals, facilities, and hospitals.1

They also learned the following:

health-insurance (1) 1. Physicians and practices must determine if patients are uninsured or paying the bill themselves without the benefit of a health insurance plan. 
bill 2. They must provide self-pay or uninsured patients with a good faith estimate (“GFE”) of the expected charges within three business days of the patient’s request and within one business day after scheduling the procedure.2
cashless-payment 3. If the final bill exceeds the GFE by $400 or more, a patient can challenge the bill by initiating a dispute resolution process through the U.S. Department of Health and Human Services.3
gavel 4. Failure to comply with the rules may result in enforcement actions by state or federal agencies, corrective action plans, and/or civil monetary penalties up to $10,000 per violation.

This patient’s bill was well below the $400 threshold but at the end of the phone call to MICA the physician and practice manager decided to rescind the fee and evaluate their communications and processes for compliance with the new rules. The patient was perturbed at first but weeks later made an appointment for another problem.

The Informed Consent Lesson

Dr. Enteman’s practice manager recalled learning in a MICA Risk Management Services hotline call that lack of informed consent is a common allegation in MPL lawsuits and licensing board investigations.

The legal standard of care generally requires physicians to obtain a patient’s informed consent and document that consent prior to a performing that procedure on the patient. “Obtaining” consent is a conversation about the purpose, benefits, and potential risks of, and alternatives to the procedure. The conversation should also include time for patient questions. “Documenting” means summarizing the conversation in a medical record entry and, ideally, in a consent form signed by the physician and the patient.

The Communication Lesson

An analysis of over 20,000 closed claims filed nationwide showed that communication was a factor in 30% of the cases.4 (3)From MICA’s risk management resources, Dr. Enteman and the practice manager knew that miscommunication between physicians, clinicians, practice staff, and patients drove the anger behind most MPL lawsuits and licensing board complaints. They reviewed some of the MPL data available through MICA and noted the following:

    • An analysis of over 20,000 closed claims filed nationwide between 2009 and 2013 showed that communication was a factor in 30% of the cases.4

    • Over half of those claims stemmed from deficiencies in physician or clinician-patient communication.5

    • Of those communications, nearly one-third involved inadequate informed consent, medication education, or an unsympathetic response to a patient complaint.6

    • Patients are more likely to report a better overall care experience with physicians, clinicians, and practice staff who are effective communicators,7 which may translate into more positive online reviews and fewer board complaints.

While talking to a MICA Risk Management Consultant, they also learned that during a panel discussion for the Arizona Society of Healthcare Attorneys Health Law Conference, the Executive Director of the Arizona Medical Board observed that better communication with patients would likely reduce complaints against physicians.8 They decided then to invite a MICA Risk Management Consultant to do a live and online or in-person presentation of effective communication closed claim data and ideas for improvement for the rest of the practice’s clinicians and staff.

Treating complaints with the same gravity that occurs during peer review, licensing board investigations, and MPL lawsuits will inspire current patients to tell the whole story with a happy ending. Even if patients are not pleased with the result, they won’t end the story there and will go on to share their experience of validation and sincerity.

MICA Members

Have a question for our Risk Management team? Or would you like to schedule a complimentary on-site or virtual assessment with one of our Risk Management consultants?

Call the Risk Management Hotline at 800-705-0538, or email rm_info@mica-insurance.com to discuss. 

If you ever need to report a potential claim or claim, please call our Claim team at (602) 956-5276 or by login to our member portal on the website

 


1 The American Medical Association’s Guide to Surprise Billing Provisions in the Consolidated Appropriations Act 2021 is a free overview of the No Surprises Act and rules. Centers for Medicare and Medicaid Services (“CMS”)’ Ending Surprise Medical Bills toolkit includes fact sheets, policy statements, training courses, and other additional information such as the rules do not apply to beneficiaries or enrollees in Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE. These programs include consumer protection requirements.

2 CMS published frequently asked questions and answers specific to good faith estimates for uninsured or self-pay individuals.

3 For more information about the billing dispute resolution process, see 45 CFR 149.620 updated as of March 28, 2022.

4 The Harvard Risk Management Foundation published Malpractice Risks in Communications Failures, a benchmarking report, in 2015. The report includes closed claim data and several case examples.

5 Id.

6 Id.

7 Merlino, J. (2017). Communication: A critical healthcare competency. Patient Safety & Quality Healthcare Analyses. Quality Improvement category. November 6.

8 Arizona Society of Healthcare Attorneys. 2022 Health Law Conference. Executive Professional Board Panel: Audit Trends and Enforcement from the Executive Directors of Arizona’s Professional Boards.

The content of this publication or presentation is intended for educational purposes only; is not an official position statement of Mutual Insurance Company of Arizona (MICA); and should not be considered or relied upon as professional, medical, or legal advice or as a substitute for your professional judgment. Consult your attorney about your individual situation and the applicable laws. The authors, presenters, and editors made a reasonable effort to ensure the accuracy of the information at the time of publication or presentation but do not warrant or guarantee accuracy, completeness, or currency of such information. As medical and legal information is constantly changing and evolving, check for updated information and consult your attorney before making decisions.

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