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Policy Coverage:

What is the distinction between "Claims-Made" policies and "Occurrence" policies?
What is Prior Acts Coverage?
What is a "Tail" endorsement and what does it cover?

Accounting:

How is premium billed?

Risk Management:

How long must I keep medical records?
How long must I keep billing records/schedule books, etc.?
How do I handle a non-compliant patient?
How do I terminate the physician-patient relationship?
What should I do when a managed care organization does not approve recommended treatment?

Claims:

I've received a request for release of my records. Can I release them?
What should I report to ProAd?
Will reporting an incident affect my premium or policy?
How do I report a claim?
After I have reported a claim, what should I do?
Can I choose the attorney I want to defend me?
Once an attorney has been assigned to my case, what can I expect?
Who determines whether a claim is settled?
When does information get reported to the National Practitioners Data Bank (NPDB)?
How can I obtain my Claims History for a hospital, HMO, etc.?
What must a claimant do to prove a claim of medical negligence?


 

Policy Coverage
 

Q: What is a "Tail" endorsement and what does it cover?

The correct name for the "Tail" endorsement is the Extended Reporting Period Endorsement because it extends the time to report claims beyond the termination date of coverage.

For coverage to apply under a "Tail" the alleged act or omission giving rise to the claim must have taken place on or after the retroactive date of the coverage and on or before the coverage termination date. The "Tail" endorsement covers claims arising from incidents occurring during the period of time between the retroactive date and the termination date.

ProAd’s "Tail" endorsements for medical professional liability do not have an expiration date. There are several ways for qualified Insureds to receive a professional liability "Tail" at no cost: permanent and total retirement from your professional practice after having been insured continuously with ProAd for a specified period of time; permanent and complete disability; and on death it is free to the estate. Contact your ProAd broker/agent for detailed and current information on the length of time of continuous ProAd coverage required for a free "Tail."
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Q: What is the distinction between "Claims-Made" policies and "Occurrence" policies?

A "Claims-Made" policy covers claims that are made during the policy period provided that the incident giving rise to the claim occurred on or after the retroactive date and on or before the termination date of the policy.

An "Occurrence" policy covers claims which arise from incidents which occur during the policy period regardless of when the claim is made.

In other words, in the event of a claim, coverage will be provided by:

The policy in force when the claim is made, as long as the incident which resulted in the claim occurred on or after the Retroactive Date and on or before the Termination Date, if the Insured is on a "Claims-Made" program; or

  • The policy in force when the claim is made, as long as the incident which resulted in the claim occurred on or after the Retroactive Date and on or before the Termination Date, if the Insured is on a "Claims-Made" program; or
  • The policy which was in force when the incident occurred which resulted in the claim, if the policyholder is on an "Occurrence" program.
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Q: What is Prior Acts Coverage?

Prior Acts ("Nose") coverage refers to coverage for acts that took place prior to the inception or effective date of the first Claims-Made policy written by one insurer that replaces the Claims-Made policy written by the prior insurer.

In order for a policyholder to avoid gaps in coverage it is important to remember when moving from one insurer to another that either a "Tail" or Prior Acts coverage is required.
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Accounting
 

Q: How is premium billed?

Premium is billed annually approximately 60 days prior to the effective day of the policy. The company offers a quarterly billing option that allows our policyholders the option to spread premium payments over 4 installments. Each installment is billed quarterly, approximately every 90 days after the initial bill.
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Risk Management
 

Q: How long must I keep medical records?

This varies from state to state. Contact Risk Management Services at Professionals Advocate for guidance on this issue.
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Q: How long must I keep billing records/schedule books, etc.?

These records can prove to be very important in the defense of a claim. If possible, keep them indefinitely.
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Q: How do I handle a non-compliant patient?

There are several important steps:

  • Document everything the patient has or has not done which shows his/her non-compliance.
  • Send the patient a letter (send both regular and certified mail) explaining the treatment recommended and the importance of compliance. You may indicate that continued non-compliance could result in termination of the physician-patient relationship.
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Q: How do I terminate the physician-patient relationship?

Do not terminate the relationship during an acute situation which could lead to allegations of abandonment. Send the patient a letter (both regular and certified mail) indicating your desire to terminate the relationship; your willingness to handle any emergency situations for the next 30 days; and suggestions on where to find another physician (i.e., County Medical Society). Clearly state what the patient's medical situation and needs are at this point, and let the patient know that you will be happy to furnish their new physician with a copy of the patient's medical record.

*If the patient belongs to a managed care organization, you must first check with them to determine termination protocol, if any.
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Q: What should I do when a managed care organization does not approve recommended treatment?

  • You need to go through the appeals process with the managed care entity.
  • Advise the patient your recommended treatment was not approved and give the patient their options (including paying for the recommended treatment themselves).
  • Document #1 and 2.
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Claims
 

Q: I've received a request for release of my records. Can I release them?

As a general rule you must release a copy of the records upon receipt of an authorization signed by the patient. You should not prepare new or additional chronologies or reports, even if requested. Some states have specific statutes governing this. If you have any questions about releasing your records, call the Claims Department at 800-492-0193. Should you have any suspicion that your treatment could lead to a claim or suit for medical negligence, you should request ProAd's assistance prior to further action.
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Q: What should I report to ProAd?

An Insured should immediately notify ProAd of any incident that may lead to or trigger a medical negligence claim. In the event the Insured receives a claim letter from an attorney or a lawsuit, swift reporting is crucial to allow ProAd adequate time to respond within the allotted time frame. Insureds are encouraged to contact ProAd with any questions or concerns regarding an incident.
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Q: Will reporting an incident affect my premium or policy?

Simply reporting an incident has no impact on your premium.
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Q: How do I report a claim?

Contact the ProAd Claims Department and provide the needed preliminary information. Contact can be via telephone (800-492-0193), fax (410-785-1670), or mail (Claims Department, Professionals Advocate, 225 International Circle, Box 8016, Hunt Valley, MD 21030). Please include:

  • Patient’s name, gender, age, marital status, address and employment status .
  • Names of any other physicians involved in care .
  • Names of any involved hospitals, clinics, etc.
  • Chronology of medical treatment including dates of treatment.
  • Any information available regarding the nature of the claim.
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Q: After I have reported a claim, what should I do?

After reporting an incident, you will be given a list of precautions to follow. It is important that you adhere to these admonitions, as they will help to preserve the integrity of your case.  

  • Do not discuss the circumstances surrounding the incident with anyone other than the attorney representing you or a ProAd Claim Representative.
  • Do not make any additions or deletions to the patient’s records.
  • Do not respond to any inquiries regarding the patient before contacting ProAd.
  • Do not respond to any legal papers before contacting ProAd.
  • Do not review any medical literature specific to the alleged or potential claim. Defense counsel advises such actions are potentially discoverable and should be undertaken only upon specific direction of counsel representing you.
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Q: Can I choose the attorney I want to defend me?

ProAd has a listing of law firms throughout the region that have been approved by our Claims Department. These firms specialize in the advocacy of physicians and their performance is monitored to ensure that they follow our guidelines and defense philosophy. We will make every effort to work with the Insured to provide counsel with whom he or she feels comfortable.
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Q: Once an attorney has been assigned to my case, what can I expect?

Initially you will be contacted to schedule an initial interview with your attorney and/or the ProAd Claims Representative. During this meeting you will be advised what to expect from the litigation process as well as discussing your case specifically. It is helpful if you have available the original medical chart and a copy of your CV.
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Q: Who determines whether a professional liability claim is settled?

ProAd will not settle your case without your knowledge. It is the policy of ProAd not to settle without the express written consent of the Insured.
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Q: When does information get reported to the National Practitioners Data Bank (NPDB)?

The information is reported to the NPDB only when the company makes a payment on behalf of an Insured. A situation could exist where there is a judgment against an Insured and the Insured chooses to pay that himself/herself. In that case, it is not reportable. The same would apply if the Insured pays a settlement himself/herself.
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Q: How can I obtain my Claims History for a hospital, HMO, etc.?

Requests for Claims Histories must be in writing and signed by the Insured. The request should include the Insured’s name, license number, policy number (if not insured under your own name), and the specific years which the history should address. The Claims History will be mailed or faxed to the current address on your policy, as requested. The Claims History will also be mailed directly to the requesting institution. In the event further information is required regarding a closed claim, please write to the Claims Department, Professionals Advocate, 225 International Circle, Box 8016, Hunt Valley, MD 21030 and specify what further information is required. In the event you need additional information regarding a pending claim, contact the attorney retained to represent you in that case.
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Q: What must a claimant do to prove a claim of medical negligence?

In general, to prove a claim of medical malpractice three basic elements must be present. These are:

  1. Negligence – defined as a departure from the accepted standard of care.
  2. Causation – there must be a causal link between the negligence of the defendant and the damages suffered by the claimant.
  3. Damages – which must be verifiable and suffered by the claimant(s).
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