An occurrence is defined as any unforeseen complication or unusual event in which a plan member is involved. Examples of occurrences are:
** Complication of drug, treatment, or service prescribed
** Dissatisfaction angrily expressed with threats
** Delay in care, diagnosis or referral
** Breach of confidentiality
** Receipt of a Notice of Intent to initiate litigation against a contracted physician or facility
An adverse incident is defined as an event over which health care personnel could exercise control and which is associated in whole, or in part with medical intervention rather than the condition for which such intervention occurred and which results in one of the following:
** Unexpected death of a patient
** Brain or spinal damage
** Performance of surgical procedure on the wrong patient
** Performance of wrong site surgical procedure
** Performance of a wrong site surgical procedure
** Performance of a surgical procedure that is medically unnecessary or otherwise unrelated to the patient’s diagnosis or medical condition
** Surgical repair of damage resulting to a patient from a planned procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process
** Performance of procedure to remove unplanned foreign objects remaining from a surgical procedure
** Never Events – as per CMS guidelines
In the state of Florida, occurrences and adverse events must be reported to the CarePlus Risk Manager within 3 calendar days, F.S. 59A-12.012. The information submitted to CarePlus is used for state mandated risk management review.
Independent physicians or private practice physicians and their health plan medical director.
** Telephonically between the independent physician and the health plan medical director.
** Telephonically between the office staff and the health plan risk manager or provider representative.
** In writing by completing a Member Occurrence Report, filled out by the independent physician or office staff. For your convenience we have included a copy of the Member Occurrence Report under the “Forms” section of this Manual. The report should be mailed to the Risk Manager, Medical Director, or the designated Provider Service Executive. Facsimiles should be avoided because of lack of confidentiality.
Group physicians and their staffs should use the following methods:
** Telephonically between the group medical director/group leader and the health plan medical director.
(The group physician, who becomes aware of an occurrence, should report the occurrence to the group medical director/group physician leader.)
** Telephonically between the office staff and the health plan risk manager or provider representative.
** In writing by completing a Member Occurrence Report filled out by the group medical director/group physician leader or office staff. The report should by mailed to the risk manager, medical director, or the designated provider representative. Facsimiles should be avoided because of lack of confidentiality.
Note: Allied health care professionals should report to their supervising physician. All other health care providers should report as independent physicians.
The information submitted to the health plan is used to investigate potential quality issues and for risk management review. All information reported to the health plan will remain strictly confidential in accordance with the policy and procedure on confidentiality.
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