Please call our Claims Intake Hotline toll-free at 877-778-2524 or email ReportClaim@ProAssurance.com.

Having the following information and documents at hand will help save you time.

• Patient or claimant name and date of birth
• Documents outlining the allegations, dates of alleged negligence, and/or request for appearance
• Date you received the documents, along with how they were received
• A copy of the patient’s medical records, if available
• A copy of the incident report completed by you, if available
• The name and address of the contact person at your practice
• The best time to reach that individual

Contact ProAssurance Claims Intake immediately if:

• You or your practice receive legal papers naming you, your practice, or any of your practice’s employees as a defendant.
• A patient or patient’s relative demands compensation for medical services you or your practice provided. 
• A patient or patient’s relative delivers a verbal or written threat to pursue legal action as a result of treatment you or your practice provided.
• An attorney contacts you about the care and treatment given to a patient.
• You receive a request for a patient’s medical records for reasons other than transfer of care.
• An adverse event occurs that you think could become a claim.
• You receive a licensure or board complaint.

The sooner ProAssurance is aware of medical incidents that could potentially lead to legal proceedings or patient complaints, the better. Situations which may lead to a claim include:

• A patient experiences a significant, unexpected adverse outcome.
• You suspect an error or omission occurred in providing medical treatment.
• A patient expresses dissatisfaction with the treatment you provided.
• Another healthcare provider is involved in a legal action with one of your current or previous patients.
• A member of your staff informs you of a potential patient incident.

To help prevent incurring fines or breaching patient confidentiality, consider developing a process for responding to subpoenas in the timely and proper manner required by law. A subpoena can be for medical records or witness testimonies. A subpoena response policy should include the following elements:

• Designate someone (and a backup) to follow up on all subpoenas received.
• Develop and use a log to record the receipt of the subpoena with the date and time, the name of the server (if served in person), and the initials of the receiver.
• If you receive a subpoena contact the Claims Intake Line at 877-778-2524 or ReportClaim@ProAssurance.com. A ProAssurance Claims Specialist will help determine the validity of a subpoena, what process applies to the type of subpoena received, and what you can or cannot release in response to the subpoena.
• Designate who will locate relevant records and who will review them before release.
• With the help of the Proassurance Claims Specialist, describe the circumstances in which a physician will review the records before releasing them.
• Describe the process for copying the records and for calculating the copying and delivery fees you may charge. All applied fees should be in accordance with state law and HIPAA regulations.

For more information on responding to subpoenas, see the Two Minutes: What's the Risk? video, “Responding to Subpoenas.”

An internal incident report is meant to provide an objective, factual description of an adverse event. It can be maintained in a traditional paper format or electronically, kept outside the medical record, should remain confidential and should not be provided to patients.

Download Sample Incident Report Form

The patient portal may be used to increase efficiency and patient engagement. However, it is not a substitute for telephone discussions or face-to-face encounters with patients. If you are utilizing a patient portal, consider the following:

• Utilize a disclaimer on the portal that clearly states it is not to be used for emergencies/urgent problems and include instructions for patients to call 911 or go to the nearest emergency department.
• Educate patients on portal use and consider using a patient portal user agreement.
• Comply with HIPAA Privacy and Security Rules and relevant state laws.
• If the communication is complex or clinically significant, or if a patient requires repeated instruction, consider an appointment for a face-to-face encounter.

Take precautions before protected health information (PHI) is texted or emailed. Using a secure application associated with your electronic medical record (EMR) is likely the safest and easiest way to ensure your texts and email remain private and secure. If email and texting applications are not integrated with your EMR, make certain communications are documented in the patient’s medical record.

Given the rise in enforcement of compliance with HIPAA and HITECH, healthcare facilities should address texting as part of the HIPAA-required risk analysis and implement “reasonable and appropriate” security measures to control and minimize the risks. Consider establishing a HIPAA-Compliant Personal Device Policy.

For additional strategies, contact the Risk Management Department. Please also see the Two Minutes: What’s the Risk? video Text Messaging Risks.

Telephone triage is the practice of reviewing, developing, and documenting a plan to resolve the patient’s specific medical complaints and symptoms. Recommendations may be given to the patient to determine when/where to access treatment.

• Have triage guidelines approved and reviewed annually by a physician. See sample below.
• Outline specific frequently asked questions and recommended responses.
• Train staff to assist patients via telephone using physician-approved, established guidelines and protocols.
  • Have all telephone encounters reviewed by the provider.
  • Document triaged calls in the patient’s medical record.

Download Telephone Triage Guidelines.

• Document all after-hours calls in the medical record.
• Discuss with the on-call physician all patient concerns and treatment plans.
• Document all communications between on-call and attending physicians in the medical record.
• Each morning a list of patients who contacted the on-call physician should be received from the on-call service.  

Federal law mandates that certain reasonable accommodations be provided for patients with communication disabilities and mandates that non-English-speaking patients receive equal access to healthcare. Failure to accommodate could have significant consequences and lead to potential liability.

Communication recommendations in these Guidelines are intended to help prevent medical professional liability lawsuits arising from miscommunications with patients who are deaf or hard of hearing, are blind or have low vision, and have limited English proficiency (LEP). Achieving full compliance with the ADA, Title VI of the Civil Rights Act, and related regulations—as well as any state or local laws—is a separate legal matter. Consult your attorney for regulatory compliance assistance with those matters.

The Americans with Disabilities Act (ADA) prohibits discrimination against individuals disabilities, including those who are deaf or hard of hearing, in places of public accommodation. Under Title III of the Act, a healthcare provider’s office is a place of public accommodation.

Reasonable accommodations for a patient who is deaf or hard of hearing will vary depending on the circumstances of each case. When treating such a patient, determine the best method of communication prior to the visit.

Ensure agreed upon communication methods are accurate, effectively convey medical terminology, and maintain confidentiality. There are numerous options for communicating with patients who are deaf or hard of hearing, including:

• Qualified interpreters
• Note takers
• Computer-aided transcription services
• Written materials or visual aides
• Assistive listening systems and devices
• Videotext displays

Document the applicable accommodation(s) in the medical record.

Reasonable accommodation must also be provided for patients who are blind or have low vision. Ensure agreed upon communication methods are accurate, effectively convey medical terminology, and maintain confidentiality. There are numerous options for communicating with such patients, including:

• Qualified readers
• Providing printed materials in large print, or Braille
• Computer screen-reading programs

Document the applicable accomodation(s) in the medical record.

Additional guidance on accommodating patients who are blind or have low vision is available through the American Foundation for the Blind.

Federal law prohibits discrimination based on race, color, or national origin. Consequently, healthcare providers must ensure that patients who do not speak English as their primary language and who have difficulty communicating effectively in English receive equal, meaningful access to medical care. Consult the U.S. Department of Health & Human Services (HHS) website for guidelines and answers to frequently asked questions.

 There are numerous options for accommodating LEP patients, including:

• Bilingual staff
• Telephone or videoconference interpreting services
• Sharing costs of resources or services with other practices
• Qualified interpreters
• Community resources and volunteers
• Written transcription and translation services

It is the provider’s responsibility to afford competent interpreter services at no cost to the patient. Ensure that any method utilized:  

• Is accurate and effectively conveys medical terminology*
• Maintains confidentiality
• Includes any necessary business associate agreements
• Is documented in the medical record as the method used for communication

*Special note: Use caution when patients insist on having family or friends translate for them. All other viable alternatives should be explored before considering translation services from family or friends. If it is necessary to have family or friends translate, providers should ensure the proffered translator can understand the English and medical terminology used. For detailed guidance on this issue, refer to the federal guidelines available at HHS.gov.

In today's digital age, online reviews and social media comments can influence patient perceptions and health care decisions. Negative reviews can be particularly impactful, potentially affecting a healthcare providers reputation and patient trust. Responding to negative reviews or comments in healthcare is a crucial practice that allows providers to address concerns, demonstrate professionalism, and show a commitment to patient care and improvement. Properly managed responses can not only mitigate the effects of negative feedback, but also turn a dissatisfied patient into a loyal advocate.

If you are part of a large group, contact your group administrator or medical director regarding policies related to online social media prior to posting or responding to negative or positive information.

• Do not respond immediately or impulsively. Not all negative comments are worthy of a response. Engaging someone may start a chain reaction of negative comments and insults and may potentially lead to litigation.
• If you feel the information is untrue, inappropriate, or simply meant to be provocative, try contacting the website administrator. Since rating sites have content guidelines, the administrator may remove information that violates the site’s terms. For example, Yelp will remove posts for various reasons.
• Ensure compliance with HIPAA regulations. Protect patient privacy by avoiding the disclosure of any personal health information in your responses.
• If responding with a post, without acknowledging that the reviewer was or was not a patient, request that they contact the office if they have specific questions. For example, if you are a patient in our practice, please contact our office directly to allow us to respond to and rectify any problem you may have had. Never include any protected health information (PHI) or argue a point in any response.
• Practices may want to designate an individual in their office who is responsible for taking inventory of reviews weekly or monthly. In addition to compiling information regarding how to improve patient satisfaction, this person may also reach out to dissatisfied reviewers to discuss their experience with them directly.
• If you can identify the individual as a patient:
• Review the medical record for potential issues.
• If appropriate, follow up with the patient in a non-confrontational and confidential manner to resolve the issues that led to the negative review or online comment.
• Discuss any concerns the patient may have and address them to the best of your ability. If appropriate, detail any practice changes the review may have initiated.
• If the matter is resolved, ask the patient to remove the negative review.
• Document all communication and follow-up with the patient in the medical record:
• Include dates and times you spoke with the patient, the patient’s exact concerns (use quotation marks as appropriate), your responses and recommendations, and the patient’s responses.
• If there are significant issues or a lawsuit is threatened or probable, contact the Claims Department at ReportClaim@ProAssurance.com

Additional Resources:

• ProAssurance Two Minutes: What’s the Risk? video “Patient Complaints”
• ProAssurance Two Minutes: What’s the Risk? video “Risks of Social Media”
• Gregory P. Murphy, et al. “Online Physician Reviews: Is There a Place for Them?” Risk Management and Healthcare Policy. 2019;12:85-89. DOI: 2147/RMHP.S170381
• Yelp Support Center. “Will Yelp Remove a False or Defamatory Review?”
• Tanya Albert Henry. “How to Respond to Bad Online Reviews.” American Medical Association. September 2, 2016.

For additional strategies, contact the Risk Management Department at RiskAdvisor@ProAssurance.com or 844-223-9648.

Disruptive behavior is broadly defined as patient behavior that could jeopardize the health and safety of others, or that impedes and disrupts the ability to provide healthcare. It can include threatening, profane, sexual, or offensive comments and gestures, violence, or aggression. Disruptive patients can undermine their own health by impacting the medical decision-making process and may be more likely to pursue malpractice lawsuits. By identifying common triggers of disruptive behavior, clinicians and staff can mitigate risks and foster collaborative treatment.

Recognizing Potentially Disruptive Behavior

One of the challenges of healthcare violence prevention is successfully anticipating it without unjustly profiling a patient who is not prone to violence; therefore, it is important to judge a situation by the totality of circumstances and not just on nonverbal cues.

Common Triggers

• Patient environment
• Communication issues
• Clinical factors
• Chronic underlying diseases

Communication Triggers

• What you say
• How you say it
• How you behave

Escalation Behaviors

• Pacing
• Clenching fists
• Tensing of the body
• Speaking loudly
• Glaring eye contact
• Invading personal space

Risk Reduction Strategies

Consider the following strategies for addressing disruptive patient behavior:

• Review and document all incidents:
  • Objectively record the details of disruptive patient encounters in the patient’s record, including your response to the behavior.
  • Review each incident of workplace violence.
  • Debrief with involved individuals following an incident.
  • Detailed encounter reports should be kept separate from the medical record.
• Develop a reporting structure:
  • Report incidents to law enforcement and state authorities as necessary, pursuant to workplace violence regulations and guidelines.
  • Develop patient behavior policies and procedures including when to call 911.
  • Create a disruptive behavior flag in the EHR, or request that one be created.
• Prepare your staff and practice environment:
  • Provide staff education.
  • If possible, install security cameras and security alarms, simplify exit routes, install metal detectors and barrier protections, install panic buttons in strategic locations, improve lighting, and control access in and out of facilities.
  • Conduct risk assessments regularly to evaluate preparedness for workplace violence.
• End the physician patient relationship if necessary.

ProAssurance Resources for Managing Disruptive Patient Behavior

Claims Rx

• Disruptive Patient Behavior: Mitigation and Management Strategies

Article Library

• Disruptive Patient Behavior: Case Studies and Best Practices
• Case Study: Failure to Document Disruptive Patient Behavior
• Case Study: Failure to De-escalate Disruptive Patient Behavior
• Case Study: Strategies for Terminating Treatment of Disruptive Patients
• Best Practices: Addressing Service and Clinical Failures with Disruptive Patients
• Best Practices: Recognizing the Triggers of Disruptive Patient Behavior

Sample Forms, Checklists, and Letters

• Patient Behavior Agreement Form
• Event Occurrence Form
• Notice of Inappropriate Behavior Form
• Patient Termination Form

Risk Management Bundle

• Workplace Violence in Healthcare

Fee disputes and collection actions can be prime triggering mechanisms for dissatisfied patients to file a medical professional liability claim.

Consider the following:

• Involve the physician in billing and collection decisions. Have the physician review patient records before they are sent to a collection agency.
• Do not place correspondence regarding billing and collection in the clinical section of the patient’s medical record.

Before considering refunds, fee reductions, or waivers for patients who are dissatisfied with medical care, it is important that you contact your ProAssurance Claims Specialist (877-778-2524 or ReportClaim@ProAssurance.com).

Establish a tracking system to document and follow up on patients referred for diagnostic, imaging, or laboratory studies. An effective system will verify all of the following steps are complete:

• The test is performed.
• The results are reported to the office.
• The physician reviews the results.
• The physician communicates the results to the patient.
• The results are acted upon.
• The results are recorded in the medical record.

Establish and implement a tracking system including the following to document and follow-up on patient referrals for specialty care.

• Documentation of the Patient’s understanding of the rational and medical necessity for the referral
• A record of the referral request in the patient’s medical record
• Documentation in the patient’s medical record of discussions with the referring or consulting physician
• Copies of letters or other forms of communication
• Timely review of and follow-up on all open referrals
• Documentation in the medical record of contacts with patients who fail to follow up with recommended referrals
• Delivery of the consultant’s recommendations to the referring physician, which may include calling the specialist for further discussion if needed
• Documentation in the medical record when a physician refers a patient for treatment or consultation as well as the results of the referral or consultation
• Communication of the results to the patient and documentation of them in the medical record

For additional information, see the U.S. Centers for Medicare & Medicaid Services Transforming Clinical Practice Initiative (TCPI) module Managing Referrals – Providing a Patient-Centered Referral Experience.

It is prudent for the physician or allied healthcare professional (e.g., nurse practitioner or physician assistant) to review all missed or cancelled appointments. To help ensure tracking and follow-up of cancellations and no-shows, consider the following.

• Document in the medical record when patients miss, cancel, or attempt to reschedule appointments.
• The results of the physician’s review should dictate any indicated follow-up measures.
• Patients with more urgent conditions may require more aggressive efforts.
• You may wish to send a certified letter to the patient and keep a copy of the letter and the return receipt.
• Document all follow-up efforts in the medical record.

• Use a tracking process to close the loop on ordered labs, specialist referrals, and diagnostic test results. Review current workflows and processes for gaps in tracking.
• Follow up with patients when they miss or cancel appointments.
• Document each attempted or completed patient communication concerning outstanding appointments, referrals, or orders.
• Educate staff on the process of referrals, ordered labs, and diagnostic test results to avoid process failures which may result in omission or delay in treatment.
• Develop a process when a provider or physician leaves the practice or is not available to ensure their outstanding ordered tests, referrals, and diagnostic tests are reviewed.

Sample Forms, Checklists and Letters library: “Tracking and Follow Up Sample Log”

Two Minutes: What’s the Risk? video: “Tracking and Follow Up”

Related articles:

• “Inadequate Follow Up Alleged Delayed Cancer Diagnosis and Treatment Led to Metastasis”
• “Failure to Follow Up, Manage Stone Claimed in Loss of Right Kidney Function”
• “Failure to Timely Refer for Follow-Up Alleged for Preemie’s Permanent Blindness”
• “Poor Test Result Communication Process Leads to Patient Injury”