Episode 091: Talking to Your Insurance Carrier

Speaker 1: You’re listening to Your Practice Made Perfect; support, protection, and advice for practicing medical professionals brought to you by SVMIC.

J. Baugh: Hello, everyone, and welcome to this episode of Your Practice Made Perfect. My name is J. Baugh. The topic that we're going to cover today is recognizing issues that physicians face from an insurance perspective. To help us discuss this important topic is Charmy Shrode. Charmy, welcome.

Charmy: Thank you. It's good to be here.

J. Baugh: Well, thank you for being here and taking time to talk about this important topic. Before we get started, maybe you could tell us a little bit about yourself.

Charmy: Well, I am the vice president of underwriting here at SVMIC. I've been here for 22 years, and prior to that I was with another professional liability carrier in a different state.

J. Baugh: Well, we thank you for taking the time to talk to us today. Just a reminder for our listeners, we had Charmy here last year to speak on some of the basics about malpractice insurance. In our show notes, we're going to include a link so that you can listen to the first podcast that Charmy did with us.

We would like to explore this time some of the hot topics and current issues that practicing physicians are facing and how malpractice insurance is responding to some of those issues. Now, there is a disclaimer here before we get started. It's best for physicians to call their insurance company and work through these situations with their carrier, as their personal situations need personal attention, but this episode may shed some light on the general response we are seeing in regard to some of these topics.

And so, the first hot topic that we're going to talk about today is practicing outside of your specialty. Charmy, how should you handle this with your malpractice carrier?

Charmy: It's most important that you first check with your medical board in your specialty to make sure that you are not going to jeopardize your medical board certification. For example, OB may have a limitation of seeing men. Your board certification is limited to your obstetrical and gynecological care of women. And if you start doing testosterone clinics, does that affect your medical board certification? That's just an example of something that someone would first want to consider.

After that, contacting your insurance carrier. Some insurance companies, your coverage is limited to the specialty which you applied for coverage for or where your training is in. So if you choose to take on a business venture that is outside of your medical specialty, then you would absolutely want to check with your insurance provider to make sure that there are no limitations on your policy. Once you do that, some of the questions that they are going to ask would be help us understand how your current training and past experience translates into this other environment.

For example, some of the areas that we have seen a physicians practicing outside of specialty would be an ED doc who now is asked to be a hospitalist. Does the ED training and the ED experience translate well to the environment of being on the floor, treating patients for ongoing situations and illnesses, and taking that handoff from an ED physician, or from a surgeon, or so forth. So does that translate well. We've also seen ED doctors, primary care doctors go into the Medispa environment where they are now going to open up a part of their practice or supervise a nurse practitioner who is practicing in a Medispa environment. Those types of things would certainly need to be covered and cleared with your professional carrier to make sure that there are no gaps in your coverage.

J. Baugh: Then we have situations in which physicians go into one area, practice of medicine, and then they decide maybe at some point in their career to change things slightly, and so they need to check with their carrier about whether there's coverage available in those types of situations. Is that right?

Charmy: Exactly. The practice of medicine has changed drastically, and unfortunately like any other career field, income and money sometimes drive your decision making.

J. Baugh: Right. That's true.

Charmy: Some of our physicians are seeing these cash-based options to be more appealing in this part of their career than perhaps the traditional medicine route.

J. Baugh: Let's talk about another topic that's making the news recently that a lot of people are hearing a lot of things about, and that's about the opioid crisis. Could you speak a little bit on the impact that that has on physicians and on their malpractice coverage?

Charmy: The opioid crisis is certainly a sad situation that we are in, and it's a situation that our physicians have found themselves in unintentionally. If you look back as to how we got to the point that we are now, some of it goes way back to the Medicare scoring of pain, where a physician was scored on the satisfaction or pain level of their patients and that's where that chart came into play, where you had the faces. You know, this is a grumpy face, this is a smiley face now. Where are you at on this scale of faces as far as your pain level? An orthopedic surgeon, for example, who just sawed and hammered on somebody, is supposed to have a patient not have pain. And so unfortunately, they would prescribe opioids as a source for treating that pain.

How that's been managed over the years, I think that's broadly debated. I certainly don't want to get into that at this point, but I do think that the opioid crisis has hit that in a different way in each state. In the state of Tennessee for example, there are very strict requirements now on the number of pain pills you can prescribe, opioids that you can prescribe, and if you prescribe more than that then you need to deem yourself as a certified pain clinic. Then there are certain requirements of how a pain clinic can operate.

What this does though, in doing so, while it has managed the opioid situation from a physician side a little better and putting guidelines around that, some patients who legitimately needed some of those pain medications are unable to get into those centers and get the treatment that they need. I think that physicians are at a hard place of knowing how to manage pain, treat their patients well, researching alternative pain options. There's been some great research out there on different pain medication combinations away from the opioid situation.

J. Baugh: Yeah. When I hear someone speaking about the opioid crisis, that's one of the main topics that's covered is alternative methods of trying to address pain that patients are facing. It really is unfortunate that the doctors are sort of caught between all of these forces that are happening, and they're just trying to do the best they can in order to treat patient pain.

Charmy: Exactly.

J. Baugh: Practicing physicians are dealing more these days with increasing their use of extenders, such as physician's assistants, and nurse practitioners and CRNAs, and they're increasing the scope of practice for these extenders. Is this impacting malpractice coverage and how should doctors approach this with regards to insurance?

Charmy: Every carrier manages the coverage for these allied providers differently. You would certainly want to check with your carrier to see if this is an exposure that can be added on to your physician policy, your corporate entity policy, or should the allied provider, healthcare provider have their own independent coverage. You would need to talk through what those pros and cons are, and what the coverage is, and how they overlap. Some carriers provide independent coverage for their allied healthcare providers.

At SVMIC, our extender coverage is an add-on to either the physician who is employing that provider or to the corporate entity that is employing that provider. They still have their own separate set of limits. This is somewhat unique. Many carriers take all of those allied providers and lump them into one shared limit. This is something that the entity should really investigate and look at the pros and cons to that, as well as the allied provider should understand that her or his coverage might be limited based on the exhaustion of some other healthcare provider's limit that has already been used. That would be something they would certainly want to look at is how does each insurance company that they're involved with specifically address the coverage.

J. Baugh: But at SVMIC, when it comes to covering extend or employees such as PAs and nurse practitioners, we have a separate limit of coverage for each person rather than it being all lumped together in one policy, as might be the case with other carriers.

Charmy: You are correct.

J. Baugh: Okay. Let's change gears a little bit and talk about telemedicine. It continues to grow and to change over time. As doctors experience new opportunities in this field of telemedicine, how is malpractice coverage responding to protect them?

Charmy: Telemedicine is a broad term that can be interpreted and used in many different ways, the same word meaning multiple different things. I'd like to first just back up and kind of clarify the variations in telemedicine. Telemedicine in one way would be a physician practice or a large clinic practice that allows some of the existing patients to receive care via telemedicine. Once they're an established patient, then they can call in, they can use their internet to get followup visits, and so forth. We have one clinic that I'm familiar with here that has a great service to their oncology patients. Once they are an established patient, then they can call in and check in with the nurse or the physician via telemedicine and not have to come into the office to have those followup visits. That is one way telemedicine is being used.

Another way is the broad telemedicine where Cigna and these healthcare providers are pushing for a telemedicine service. Instead of going into see a physician or a healthcare provider of any kind, you just log into your computers and get some sort of medical care that way. If a physician is going to sign up to be one of these providers, they first need to make sure they understand that their medical license is state specific. And so if they are licensed in the state of Tennessee for example, and they are sitting on their couch or in their office providing this telemedicine care, if the patient resides in a different state, it is likely that that patient, if a claim is made, it's going to be made in the state in which that patient resides.

Is it required of that physician to have had a license in that state where the patient sought care from? There are some states that have created a telemedicine mobile license that is a little bit of a limited scaled down medical license provision that allows a physician to do this type of work across state lines. That is not a universal thing at this point, and not all states have bought into this compact licensing issue, and so a physician would certainly need to make sure that they are in compliance with each state's medical licensing requirements.

Another thing that we're seeing with telemedicine that is really interesting and quite fascinating is the NICU. We are seeing NICU services where a specialist is not available, and so they are using robotic telemedicine to render care where the nurse or onsite healthcare provider taps into a physician who can see what's going on and remotely advise resuscitation or efforts in the NICU unit while not actually being on the premises. Some might call that telemedicine as well.

You can see that term has a broad spectrum. The most important thing with this topic as we're discussing today is each one of these types of scenarios should be discussed with your carrier to make sure that there's not any provision in your policy that might not extend coverage in these particular circumstances.

J. Baugh: That's interesting that you had so many different ideas for what telemedicine can mean. And you're right, it can mean different things to different people and it can apply in a lot of different scenarios, so it's good advice to check with your carrier if you decide to get into any area of telemedicine whatsoever. Let's talk a little bit about taking time off for personal reasons. Let's say a physician or another healthcare provider is experiencing burnout. Maybe they need to take maternity leave. Maybe there are other professional reasons that they need to take some time off. How would these healthcare providers work with their carrier to preserve their ability to obtain coverage upon their return to the practice of medicine?

Charmy: Again, each carrier is going to handle a hiatus from practice in various different ways. Communication and having the dialogue with your carriers is the most important thing. Some carriers you will find will actually suspend your coverage for a period of time and then charge you a runoff exposure cost for that. Some carriers will not allow any type of ongoing coverage if there is not ongoing exposure and they would require you to terminate your coverage at that time. Other carriers like SVMIC, we reduce the hours worked with a significant discount applied to enable you to continue to maintain your current coverage at a discounted rate without having to purchase tail, which can be fairly expensive. And by tail, I mean the extended reporting endorsement that would need to go on to a canceled policy.

J. Baugh: Okay. One of the issues that we're hearing more about these days unfortunately has to do with sexual misconduct as it relates to the providing of medical care. I'm wondering what we would recommend to doctors about coverage that might apply in these types of situations.

Charmy: The first thing I would say on this topic is that I would advise every physician to have a chaperone in the room at all times.

J. Baugh: Absolutely.

Charmy: I know in the past that the recommendation might have been if it's an opposite sex patient or if it is a sensitive exam to have a chaperone in the room. Unfortunately, what we're finding is that may not be enough.

J. Baugh: Right.

Charmy: While it may not be practical, that certainly is the recommendation is to have a chaperone in the room at all times. Oftentimes, your physical exam with a physician is uncomfortable, and how the patient is interpreting that uncomfortable feeling has been one of the questions these days based in the current market.

J. Baugh: Yeah, that's true. As one of the claims attorneys here at SVMIC, I am seeing that becoming an increasing issue with a physician performing an exam and then the patient interpreting what's going on in a different way. We're seeing that type of claim I think on the rise.

Charmy: I think again, communication, explaining exactly what is about to happen to the patient, why it is necessary to do the exam the way that you have to do it. Communication is the most important piece in this, in my opinion, in addition to the chaperone. But as far as your coverage goes, your insurance coverage, most policies are going to exclude any inappropriate sexual misconduct of a physician in any way. However, sometimes the allegation is that, well, it was really in the course of a medical treatment, so that's kind of splitting the hairs as far as is the allegation a medical incident or is the allegation one that falls under the sexual misconduct? Each policy probably addresses this a little bit differently. At SVMIC, we tend to give the benefit of the doubt to our insured and move towards that and defending that from a medical incident approach until such time we find that perhaps that might not be the situation. Fortunately, most of the time it is within the course of normal medical incident activity.

J. Baugh: Right. Physicians may be experiencing more business in nursing homes or long term care scenarios. So if this is the case, are they covered for this already or is there something they need to work with their malpractice carrier in order to cover?

Charmy: Again, every insurance policy and every company is going to handle this differently. So you would want to have a conversation with your specific provider to see if for some reason your policy is limited to an exposure that is outside of that of a nursing home or maybe they even exclude specifically care in long term facilities. Anybody can turn on the TV or drive through a city and see a billboard where someone is advertising the opportunity to sue a healthcare provider in one of these facilities.

J. Baugh: That's right.

Charmy: That by nature creates that type of practice to be one that invites the opportunity to get sued more. Not necessarily be held liable, but to be named in lawsuits. This can be a different change in your exposure to the insurance company versus that of perhaps a private practice or clinical based. If the majority of your practice is one that is in a facility that is being targeted as a litigation hotbed, then this would be something that you would certainly want to discuss with your insurance company to make sure that your coverage is adequate to extend to this type of exposure.

J. Baugh: Charmy, as we begin to wrap up this particular episode of this podcast, are there any last minute tips or advice on these topics that you would like to leave us with?

Charmy: I would just like to say that I think that insurance for a physician's practice is one that should be a mutual relationship where the physician is adequately communicating with their provider to make sure that they know what the exposure is, and the provider is there to help them walk through what risks and policy coverages they might need to make sure they're adequately covered. Communication is the key I think in all of this

J. Baugh: Well Charmy, we want to thank you again for spending your time today to help us talk about some of these issues as it relates to insurance coverage. I know that it's very important for many of our listeners, and like you said, communication is important to talk to their carrier about any situation they might have a question about. Once again, thank you for being here.

Charmy: You're welcome. Thank you.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host J. Baugh. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast. 

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time.