Episode 2: The Claims Process
In this episode of "New-to-Practice physicians: What you need to know," we review the claims process, from the moment a notice of claim is received to resolution.
Episode 2: The Claims Process
In this episode of "New-to-Practice physicians: What you need to know," we review the claims process, from the moment a notice of claim is received to resolution.
Cindy Garza, TMLT's Assistant Vice President of Claims Operation, provides an overview of what happens in the event of a medical malpractice claim and how TMLT will stand with you every step of the way. Running time: 14:12
Also available on Apple podcasts.
Transcript
Tony Passalacqua:
Hello, and welcome to this edition of TMLT's podcast, TrendsMD. I'm your host, Tony Passalacqua, and today we are continuing our series, New-to-Practice Physicians: What you need to know. Our guest today is Cindy Garza, TMLT's Assistant Vice President of Claims Operations, and she will be here to discuss the claims process, specifically what physicians can expect in the event of a claim or being sued. Welcome, Cindy.
Cindy Garza:
Thank you, Tony.
Tony Passalacqua:
So, I also wanted to take this time to congratulate you on your TMLT anniversary. This year marked a big milestone for you.
Cindy Garza:
Thank you, Tony. Yes. I celebrated my 30th year anniversary at TMLT.
Tony Passalacqua:
That's amazing. Can you tell us a little bit about your experience at TMLT or anything else that you would like to tell us about yourself?
Cindy Garza:
Sure. Prior to coming to TMLT, I handled general liability and workers' compensation claims. And of course for the last 30 years I've been handling medical malpractice claims here at TMLT, and I hope the information that I share today regarding the claims process will be helpful to new-to-practice physicians and others who may be listening to this.
Tony Passalacqua:
I definitely know that all the experience that you bring will help out our physicians tremendously in their future careers. So let's start with the first step in the claims process for a physician being notified of the claim. What should a physician do when they receive that notification?
Cindy Garza:
The policyholders should notify TMLT as soon as possible when they receive any of the following.
The receipt of a summons or a citation in a lawsuit; the receipt of a written notice of claim pursuant to the applicable law; the receipt of a written demand from a patient or a representative of the patient seeking compensatory damages; a notice of a state board complaint or other disciplinary action.
We also encourage them to immediately contact us if they have had a breach of patient information or a ransomware attack - this may fall under their cyber coverage of the policy - or if they have an employment matter. To notify us, they should call +1 800-580-8658. When they call in to report a claim, they should be prepared to be on the phone for about 15 to 20 minutes.
That's about how long it takes to go through the intake process. They can also report the claim by logging into MyPortal on the TMLT website. It's always a good idea to have the notice of claim or lawsuit and some of the medical records on hand when reporting so that the person taking the call can gather as much information as possible when setting up the claim file.
Tony Passalacqua:
So what if a physician doesn't receive a claim notice but is concerned about an incident with a patient that may potentially lead to a claim?
Cindy Garza:
It's always good practice for a physician to report anything that is concerning to them. For example, if they've had an unexpected outcome, perhaps a complication or some other matter that has occurred that they feel will result in a future claim - we encourage them to call us. A medical records request from the patient, the patient's spouse, an attorney, a record service, or if they receive a subpoena for the records, they should give us a call if they have any questions about whether or not to produce the records, or if they have a question as to whether the proper authorization has been received with the request. If they receive a request for deposition, either by a phone call or a subpoena for the deposition or to appear in court, we recommend that they call us. Oftentimes, they receive subpoenas or requests for deposition on underlying medical malpractice claims.
And sometimes those can lead to them being brought into a lawsuit. So we definitely want to assign defense counsel on those matters. Sometimes the physician will have questions about a patient asking for reimbursement of a service or a request to write off a bill. Again, we recommend that if they have any doubt on how to proceed, that they give us a call.
Any of these scenarios, we would create a record of the call, but they would not be instances in which a claim has been made, and they would not trigger coverage. In any of these scenarios, we would create a record of the call, but these would not be instances in which a claim has been made. However, in the event that a claim is made later.
We will already have some of this information on file to build on.
Tony Passalacqua:
So what happens once a case file is set up?
Cindy Garza:
Once a claim is set up, it is assigned to a TMLT supervisor. This is a person that will be in communication with a physician during the course of the claim or lawsuit. They will then verify the policyholder's coverage.
They will make contact with a policyholder within 48 hours to discuss the claim in more detail. If a lawsuit has been filed, we will assign defense counsel to defend the insured. Acknowledgement letters are sent out to the policyholder and to the plaintiff's attorney who is representing the patient or the patient's family.
Tony Passalacqua:
What is included in the response letter?
Cindy Garza:
The acknowledgement letter comes from the claims supervisor that has been assigned to the case. It includes a claim number for future reference and it basically acknowledges receipt of the claim or lawsuit. We request a copy of the insured's medical chart if it has not already been provided.
We further notify them to keep correspondence from us in a separate file and that it should not be placed in the patient's chart. We notify them not to discuss the case with anyone other than the TMLT representative or the defense attorney that has been assigned to the case. If it is a claim, we advise them to let us know immediately if they receive a lawsuit.
A lawsuit requires a formal response, which is referred to as an answer, and there is a deadline for filing this with serious penalties for an untimely answer.
Tony Passalacqua:
And then does that start the investigation process?
Cindy Garza:
Yes, the investigation into the claim begins with the discussion with the insured of what occurred. We also send acknowledgement letters to the plaintiff's attorney, at which time we request their specific allegations; documentation of their alleged economic damages; and copies of medical records.
Once we have had an opportunity to review all the records, we will be in a better position to evaluate the matter. Assuming we have a proper medical authorization attached to the claim, we can start requesting medical records. Once we have the pertinent medical records, we have them reviewed by medical doctors of the same specialty.
We also sometimes request reviews of different specialties. These reviewers give us opinions regarding the care and treatment and help us develop the defense of the case. If the case is in litigation, the defense attorney works with the insured on developing the defense of the case. They will retain medical records and line up expert support from whatever specialties are needed.
The litigation process has many aspects involved in the development of the defense, including interrogatories, depositions, motions, etc.
Tony Passalacqua:
So I have a quick question for you. What is the difference between a claim and a lawsuit?
Cindy Garza:
A claim can be a written notice of a claim or a written demand for compensation, or it can be a lawsuit.
A lawsuit on the other hand, is an action brought in a court of law is an escalation of a claim at a different level. Uh, claim is often a preliminary step before a lawsuit. Although sometimes the first notice of a claim is a lawsuit. Generally, if we deny the claim or cannot reach a settlement, assuming one is warranted, the plaintiff's attorney's next step is to file a lawsuit. Again, sometimes the plaintiff attorney will just file a lawsuit without prior notice.
Tony Passalacqua:
What happens if a claim stays a claim?
Cindy Garza:
If a suit is not filed, the case remains a claim. There are various scenarios that can occur after our investigation is completed. We can deny the claim. At that point, the patient or the attorney will decide if they wanna proceed with filing a lawsuit.
Sometimes they do and sometimes we simply do not hear anything further from them. There are times when the claim remains as such, because the statute of limitations expired prior to filing of a lawsuit.
Tony Passalacqua:
Is this process different if you initially receive a lawsuit instead of a claim?
Cindy Garza:
Most of the time we will already have a claim file set up and the physician should immediately call the claim supervisor or anyone in the claim department to notify them that they have been served with a lawsuit.
If this is the first notice. They should immediately call TMLT to notify us of the lawsuit. The process is basically the same except that we have signed defense counsel who specializes in medical malpractice defense. We are dealing with deadlines on multiple matters which are set by the court. The policyholder's notified of the attorney that is selected, and we will send a letter to the insured regarding this as well.
At the time the lawsuit is filed, we will notify the Texas Medical Board. And together the claim supervisor, attorney, and policyholder develop a defense strategy and we remain in communication throughout the life of the case.
Tony Passalacqua:
Cindy, what is the number to file a claim?
Cindy Garza:
Yes, it's 1-800-580-8658.
Tony Passalacqua:
Is there any advice for what a physician should avoid?
Cindy Garza:
Yes. They should avoid making any changes to the records or documentation. Especially after receiving a notice of claim or lawsuit, they should not access the patient's hospital chart after receiving a claim. And other than the TMLT claims rep and their assigned defense attorneys, they should not discuss the details of the case itself or their treatment with anyone else.
Tony Passalacqua:
So what are the next steps after the details of a claim or lawsuit are investigated?
Cindy Garza:
Once a case is in litigation, a plaintiff attorney has 120 days after an answer was filed to produce an expert report, which sets out what the standard of care is, how the insured breach of standard of care, and how that breach of the standard of care caused the injury or the outcome. If one is not filed, the lawsuit should be dismissed at that time. If an expert report is produced, the case continues and the defense attorney will continue to develop the defenses. As a case develops, a decision is made to settle the case or to proceed with trial. On occasion, depending on how the case develops or on the discovery of information and or testimony, the insured may be dismissed from the lawsuit without payment.
TMLT will not settle a case without first obtaining the written consent of the insured. Such consent may be limited by the insured. Assuming we have consent from the insured, a lawsuit can resolve at any point during the litigation through direct negotiations with the plaintiff attorney, or at mediation.
During the pendency of the lawsuit, the court will set a trial date as well as other deadlines including a mediation date deadline. Most courts - not all - require that a case be mediated prior to proceeding to trial. If the insured does not consent to settlement; or if TMLT deems that settlement is not warranted; or if an agreement cannot be reached; the case will proceed to trial.
The duration of the trial depends on the complexity of the case and the number of parties involved. The claim supervisor will attend the trial to monitor the progress of the [00:13:00] trial and support the physician during this process. If there is a defense verdict, the claim file will be closed thereafter, assuming that it is not appealed by the plaintiff.
If there is a plaintiff's verdict, TMLT, along with defense and appellate counsel, will determine if there are any grounds for appeal and will evaluate our options before proceeding to the next step. Upon completion of the lawsuit, we send a final report to the Texas Medical Board, either notifying them of the date, type, and amount of settlement, or if the case was dismissed or non-suited or successfully tried.
If the claim involves a settlement, TMLT is required to notify the National Practitioner's Data Bank.
Tony Passalacqua:
Cindy, is there anything else that you would like to say to any new-to-practice physicians who may be listening regarding the claims process?
Cindy Garza:
The claims process, and a pending lawsuit in particular, can have a significant emotional impact on any physician. New-to-practice physicians will be facing other challenges in addition to experiencing their first claim or lawsuit. We, in the Claim Department, know and understand this. We want them to know that we are here to protect and defend them, and that we will support them through the entire claims process.
Tony Passalacqua:
Thank you, Cindy, for joining us today in our podcast.
Cindy Garza:
Thank you, Tony. Thanks for having me,
Tony Passalacqua:
As always, thank you to our listeners. Please feel free to contact us with any questions by calling 1-800-580-8658, or checking out our resources by visiting us at www.tmlt.org.
Additional episodes in this series:
Disclaimer
Cindy Garza, TMLT's Assistant Vice President of Claims Operation, provides an overview of what happens in the event of a medical malpractice claim and how TMLT will stand with you every step of the way. Running time: 14:12
Also available on Apple podcasts.
Transcript
Tony Passalacqua:
Hello, and welcome to this edition of TMLT's podcast, TrendsMD. I'm your host, Tony Passalacqua, and today we are continuing our series, New-to-Practice Physicians: What you need to know. Our guest today is Cindy Garza, TMLT's Assistant Vice President of Claims Operations, and she will be here to discuss the claims process, specifically what physicians can expect in the event of a claim or being sued. Welcome, Cindy.
Cindy Garza:
Thank you, Tony.
Tony Passalacqua:
So, I also wanted to take this time to congratulate you on your TMLT anniversary. This year marked a big milestone for you.
Cindy Garza:
Thank you, Tony. Yes. I celebrated my 30th year anniversary at TMLT.
Tony Passalacqua:
That's amazing. Can you tell us a little bit about your experience at TMLT or anything else that you would like to tell us about yourself?
Cindy Garza:
Sure. Prior to coming to TMLT, I handled general liability and workers' compensation claims. And of course for the last 30 years I've been handling medical malpractice claims here at TMLT, and I hope the information that I share today regarding the claims process will be helpful to new-to-practice physicians and others who may be listening to this.
Tony Passalacqua:
I definitely know that all the experience that you bring will help out our physicians tremendously in their future careers. So let's start with the first step in the claims process for a physician being notified of the claim. What should a physician do when they receive that notification?
Cindy Garza:
The policyholders should notify TMLT as soon as possible when they receive any of the following.
The receipt of a summons or a citation in a lawsuit; the receipt of a written notice of claim pursuant to the applicable law; the receipt of a written demand from a patient or a representative of the patient seeking compensatory damages; a notice of a state board complaint or other disciplinary action.
We also encourage them to immediately contact us if they have had a breach of patient information or a ransomware attack - this may fall under their cyber coverage of the policy - or if they have an employment matter. To notify us, they should call +1 800-580-8658. When they call in to report a claim, they should be prepared to be on the phone for about 15 to 20 minutes.
That's about how long it takes to go through the intake process. They can also report the claim by logging into MyPortal on the TMLT website. It's always a good idea to have the notice of claim or lawsuit and some of the medical records on hand when reporting so that the person taking the call can gather as much information as possible when setting up the claim file.
Tony Passalacqua:
So what if a physician doesn't receive a claim notice but is concerned about an incident with a patient that may potentially lead to a claim?
Cindy Garza:
It's always good practice for a physician to report anything that is concerning to them. For example, if they've had an unexpected outcome, perhaps a complication or some other matter that has occurred that they feel will result in a future claim - we encourage them to call us. A medical records request from the patient, the patient's spouse, an attorney, a record service, or if they receive a subpoena for the records, they should give us a call if they have any questions about whether or not to produce the records, or if they have a question as to whether the proper authorization has been received with the request. If they receive a request for deposition, either by a phone call or a subpoena for the deposition or to appear in court, we recommend that they call us. Oftentimes, they receive subpoenas or requests for deposition on underlying medical malpractice claims.
And sometimes those can lead to them being brought into a lawsuit. So we definitely want to assign defense counsel on those matters. Sometimes the physician will have questions about a patient asking for reimbursement of a service or a request to write off a bill. Again, we recommend that if they have any doubt on how to proceed, that they give us a call.
Any of these scenarios, we would create a record of the call, but they would not be instances in which a claim has been made, and they would not trigger coverage. In any of these scenarios, we would create a record of the call, but these would not be instances in which a claim has been made. However, in the event that a claim is made later.
We will already have some of this information on file to build on.
Tony Passalacqua:
So what happens once a case file is set up?
Cindy Garza:
Once a claim is set up, it is assigned to a TMLT supervisor. This is a person that will be in communication with a physician during the course of the claim or lawsuit. They will then verify the policyholder's coverage.
They will make contact with a policyholder within 48 hours to discuss the claim in more detail. If a lawsuit has been filed, we will assign defense counsel to defend the insured. Acknowledgement letters are sent out to the policyholder and to the plaintiff's attorney who is representing the patient or the patient's family.
Tony Passalacqua:
What is included in the response letter?
Cindy Garza:
The acknowledgement letter comes from the claims supervisor that has been assigned to the case. It includes a claim number for future reference and it basically acknowledges receipt of the claim or lawsuit. We request a copy of the insured's medical chart if it has not already been provided.
We further notify them to keep correspondence from us in a separate file and that it should not be placed in the patient's chart. We notify them not to discuss the case with anyone other than the TMLT representative or the defense attorney that has been assigned to the case. If it is a claim, we advise them to let us know immediately if they receive a lawsuit.
A lawsuit requires a formal response, which is referred to as an answer, and there is a deadline for filing this with serious penalties for an untimely answer.
Tony Passalacqua:
And then does that start the investigation process?
Cindy Garza:
Yes, the investigation into the claim begins with the discussion with the insured of what occurred. We also send acknowledgement letters to the plaintiff's attorney, at which time we request their specific allegations; documentation of their alleged economic damages; and copies of medical records.
Once we have had an opportunity to review all the records, we will be in a better position to evaluate the matter. Assuming we have a proper medical authorization attached to the claim, we can start requesting medical records. Once we have the pertinent medical records, we have them reviewed by medical doctors of the same specialty.
We also sometimes request reviews of different specialties. These reviewers give us opinions regarding the care and treatment and help us develop the defense of the case. If the case is in litigation, the defense attorney works with the insured on developing the defense of the case. They will retain medical records and line up expert support from whatever specialties are needed.
The litigation process has many aspects involved in the development of the defense, including interrogatories, depositions, motions, etc.
Tony Passalacqua:
So I have a quick question for you. What is the difference between a claim and a lawsuit?
Cindy Garza:
A claim can be a written notice of a claim or a written demand for compensation, or it can be a lawsuit.
A lawsuit on the other hand, is an action brought in a court of law is an escalation of a claim at a different level. Uh, claim is often a preliminary step before a lawsuit. Although sometimes the first notice of a claim is a lawsuit. Generally, if we deny the claim or cannot reach a settlement, assuming one is warranted, the plaintiff's attorney's next step is to file a lawsuit. Again, sometimes the plaintiff attorney will just file a lawsuit without prior notice.
Tony Passalacqua:
What happens if a claim stays a claim?
Cindy Garza:
If a suit is not filed, the case remains a claim. There are various scenarios that can occur after our investigation is completed. We can deny the claim. At that point, the patient or the attorney will decide if they wanna proceed with filing a lawsuit.
Sometimes they do and sometimes we simply do not hear anything further from them. There are times when the claim remains as such, because the statute of limitations expired prior to filing of a lawsuit.
Tony Passalacqua:
Is this process different if you initially receive a lawsuit instead of a claim?
Cindy Garza:
Most of the time we will already have a claim file set up and the physician should immediately call the claim supervisor or anyone in the claim department to notify them that they have been served with a lawsuit.
If this is the first notice. They should immediately call TMLT to notify us of the lawsuit. The process is basically the same except that we have signed defense counsel who specializes in medical malpractice defense. We are dealing with deadlines on multiple matters which are set by the court. The policyholder's notified of the attorney that is selected, and we will send a letter to the insured regarding this as well.
At the time the lawsuit is filed, we will notify the Texas Medical Board. And together the claim supervisor, attorney, and policyholder develop a defense strategy and we remain in communication throughout the life of the case.
Tony Passalacqua:
Cindy, what is the number to file a claim?
Cindy Garza:
Yes, it's 1-800-580-8658.
Tony Passalacqua:
Is there any advice for what a physician should avoid?
Cindy Garza:
Yes. They should avoid making any changes to the records or documentation. Especially after receiving a notice of claim or lawsuit, they should not access the patient's hospital chart after receiving a claim. And other than the TMLT claims rep and their assigned defense attorneys, they should not discuss the details of the case itself or their treatment with anyone else.
Tony Passalacqua:
So what are the next steps after the details of a claim or lawsuit are investigated?
Cindy Garza:
Once a case is in litigation, a plaintiff attorney has 120 days after an answer was filed to produce an expert report, which sets out what the standard of care is, how the insured breach of standard of care, and how that breach of the standard of care caused the injury or the outcome. If one is not filed, the lawsuit should be dismissed at that time. If an expert report is produced, the case continues and the defense attorney will continue to develop the defenses. As a case develops, a decision is made to settle the case or to proceed with trial. On occasion, depending on how the case develops or on the discovery of information and or testimony, the insured may be dismissed from the lawsuit without payment.
TMLT will not settle a case without first obtaining the written consent of the insured. Such consent may be limited by the insured. Assuming we have consent from the insured, a lawsuit can resolve at any point during the litigation through direct negotiations with the plaintiff attorney, or at mediation.
During the pendency of the lawsuit, the court will set a trial date as well as other deadlines including a mediation date deadline. Most courts - not all - require that a case be mediated prior to proceeding to trial. If the insured does not consent to settlement; or if TMLT deems that settlement is not warranted; or if an agreement cannot be reached; the case will proceed to trial.
The duration of the trial depends on the complexity of the case and the number of parties involved. The claim supervisor will attend the trial to monitor the progress of the [00:13:00] trial and support the physician during this process. If there is a defense verdict, the claim file will be closed thereafter, assuming that it is not appealed by the plaintiff.
If there is a plaintiff's verdict, TMLT, along with defense and appellate counsel, will determine if there are any grounds for appeal and will evaluate our options before proceeding to the next step. Upon completion of the lawsuit, we send a final report to the Texas Medical Board, either notifying them of the date, type, and amount of settlement, or if the case was dismissed or non-suited or successfully tried.
If the claim involves a settlement, TMLT is required to notify the National Practitioner's Data Bank.
Tony Passalacqua:
Cindy, is there anything else that you would like to say to any new-to-practice physicians who may be listening regarding the claims process?
Cindy Garza:
The claims process, and a pending lawsuit in particular, can have a significant emotional impact on any physician. New-to-practice physicians will be facing other challenges in addition to experiencing their first claim or lawsuit. We, in the Claim Department, know and understand this. We want them to know that we are here to protect and defend them, and that we will support them through the entire claims process.
Tony Passalacqua:
Thank you, Cindy, for joining us today in our podcast.
Cindy Garza:
Thank you, Tony. Thanks for having me,
Tony Passalacqua:
As always, thank you to our listeners. Please feel free to contact us with any questions by calling 1-800-580-8658, or checking out our resources by visiting us at www.tmlt.org.
Additional episodes in this series:
Disclaimer
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