What Is Medical Malpractice?

In medical malpractice, a doctor or medical facility has failed to live up to its obligations, resulting in a patient’s injury. Medical malpractice is usually the result of medical negligence – a mistake that was unintentional on the part of the medical personnel.

Determining if malpractice has been committed during medical treatment depends on whether the medical personnel acted in a different way than most professionals would have acted in similar circumstances. For example, if a nurse administers a different medication to a patient than the one prescribed by the doctor, that action differs from what most nurses would have done.

Surgical malpractice is a very common type of case. A cardiac surgeon, for example, might operate on the wrong heart artery or forget to remove a surgical instrument from the patient’s body before stitching the incisions closed.

Not all medical malpractice cases are as clear-cut, however. The surgeon might make a split-second decision during a procedure that may or may not be construed as malpractice. Those kinds of cases are the ones that are most likely to end up in a courtroom.

The majority of medical malpractice lawsuits are settled out of court, however, which means that the doctor’s or medical facility’s malpractice insurance pays a sum of money called the “settlement” to the patient or patient’s family.

This process is not necessarily easy, so most people are advised to hire an attorney. Insurance companies do their best to keep the settlement amounts as low as possible. A lawyer is in a position to help patients prove the severity of the malpractice and negotiate a higher sum of money for the patient/client.

Lawyers generally work on “contingency” in these types of cases, which means they are only paid when and if a settlement is received. The lawyer then takes a percentage of the total settlement amount as payment for his or her services.

Different Types of Medical Malpractice

There are different kinds of malpractice cases that are a result of a variety of medical mistakes. Besides surgical errors, a few of these cases include:

Medical chart mistakes – In this case, a nurse or physician makes an inaccurate note on a medical chart that leads to more mistakes, such as the wrong medication being administered or an incorrect medical procedure being performed. This could also lead to a lack of proper medical treatment.

Improper prescriptions – A doctor might prescribe the wrong medication, or a pharmacist might fill a prescription with the wrong medication. A doctor may also fail to check what other medications a patient is taking, causing one medication to mix in a dangerous way with the other. Some pharmaceuticals are “contraindicated” for certain conditions. It might be hazardous, for example, for a heart patient to take a particular medication for an ulcer. This is why doctors need to know a patient’s medical history.

Anesthesia – These kinds of medical malpractice claims are usually made against an anesthesiologist. These professionals give patients medication to put them to sleep during an operation. The anesthesiologist usually remains in the operating room to monitor the patient for any signs that the anesthesia is causing problems or wearing off during the procedure, causing the patient to awaken too soon.

Delayed diagnosis – This is one of the most common types of non-surgical medical malpractice cases. If a doctor fails to determine that someone has a serious illness, that doctor might be sued. This is especially dire for cancer patients who need to detect the disease as early as possible. A wrong diagnosis can cause the cancer to spread before it has been detected, endangering the patient’s life.

Misdiagnosis – In this case, the physician diagnoses a patient as having a disease other than the correct condition. This can lead to unnecessary or incorrect surgery, as well as dangerous prescriptions. It can also cause the same injuries as delayed diagnosis.

Childbirth malpractice – Mistakes made during the birth of a child can result in permanent damage to the baby and/or the mother. These kinds of cases sometimes involve a lifetime of payments from a medical malpractice insurance company and can, therefore, be extraordinarily costly. If, for instance, a child is born with brain damage as a result of medical malpractice, the family might be awarded regular payments in order to care for that child throughout his or her life.

What Happens in a Medical Malpractice Case?

If someone believes they have suffered harm as a result of medical malpractice, they must file a lawsuit against the responsible parties. These parties might include an entire hospital or other medical facility, as well as a number of medical personnel. The patient becomes the “plaintiff” in the case, and it is the burden of the plaintiff to prove that there was “causation.” This means that the injuries are a direct result of the negligence of the alleged medical professionals (the “defendants.”)

Proving causation usually requires an investigation into the medical records and may require the assistance of objective experts who can evaluate the facts and offer an assessment.

The settlement money offered is often restricted to the amount of money lost as a result of the injuries. These losses include medical care costs and lost wages. They can also include “loss of consortium,” which is a loss of benefits of the injured patient’s spouse. Sometimes, money for “pain and suffering” is offered, which is a non-financial payout for the stress caused by the injuries.

Money for “punitive damages” is legal in some states, but this generally occurs only in situations where the negligence was extreme. In rare cases, a physician or medical facility is found to be guilty of gross negligence or even willful malpractice. When that happens, criminal charges may also be filed by the local authorities.

In examples of gross negligence, the health department might revoke a doctor’s medical license. This does not happen in most medical malpractice cases, however, since doctors are human and, therefore, all capable of making mistakes.

If the plaintiff and the defendant’s medical malpractice insurance company cannot come to an agreeable sum for the settlement, the case might go to trial. In that instance, a judge or a jury would decide the amount of money, if any, that the plaintiff/patient would be awarded for his or her injuries.

What Is Medical Negligence?

Medical negligence occurs when medical treatment falls below expected standards. If a patient becomes injured as a result of medical negligence, that patient might file a lawsuit claiming medical malpractice. If a patient dies, the family might then file a wrongful death lawsuit.

The most common type of medical negligence involves surgery, but it can happen with any nurse, physician, medical technician, or medical facility. The different types of medical negligence are almost endless. Here are some examples:

Damage to a neighboring organ during surgery.
A wrong diagnosis that leads to no treatment for the condition or the incorrect treatment for the condition.
A doctor who tells a patient that he or she is okay, causing a delay in treatment that eventually leads to injury. This is especially dire if an illness is progressive, such as cancer.
A dentist whose negligent treatment causes the patient to lose teeth.
An incorrect medication or the prescription of a medication in a harmful dosage. This can be negligence on the part of a doctor prescribing the medication, a nurse administering the medication, or a pharmacist.
Unnecessary surgery that results, for example, in the inability of the patient to have children.
A botched cosmetic procedure that causes an injury or a severely displeasing result.
A medical instrument accidentally left inside a patient during surgery.
Mistakes on a medical chart that lead to incorrect medical procedures or medications.
Improper or ineffective anesthesia administered prior to surgery.
A mistake made during childbirth that leads to the death of the infant or permanent injury to the infant, such as brain damage. Cerebral palsy is often a result of this kind of medical negligence.

The Difficulty of “Causation”

In order for a patient to have a medical malpractice claim for medical negligence, he or she has to prove (1) that the medical professionals had a duty to provide a standard of care and failed to do so, (2) that the patient suffered an injury or injuries, and (3) that the injury was caused by the alleged medical negligence.

What does “standard of care” mean? It varies from state to state. Some laws restrict the standard to physicians in the same area of the country, while others extend the standard to doctors on a national level. For example, a heart surgeon will be held to the standard of other surgeons in the same field. If he or she acted in a way that differs from the way most heart surgeons would have acted in similar circumstances, that surgeon may be found to have been medically negligent.

Since the body consists of interconnected systems, “causation” is a complicated issue in medical negligence. The medical personnel might argue that the treatment did not cause the injury but that it was instead caused by a condition the patient already had.

Psychologists and psychiatrists can also be sued for medical negligence, although these types of cases are much more difficult to prove because not only are the injuries non-physical, but causation is particularly complex.

In any type of case, the attorneys assigned by the physicians’ malpractice insurance company will likely try to argue that the injury was not caused by medical negligence.

For this reason, people who suffer injuries are advised to hire a lawyer to help them negotiate a settlement to recover the costs they incurred. Lawyers in this situation work on a “contingency” basis, which means that they do not require the client to pay them. Their fees are contingent upon receiving settlement monies from the medical malpractice insurance company. If the lawyer is successful in obtaining a settlement for the client, he or she then takes a percentage of the money as a fee. If the lawyer is not successful, he or she does not earn any money for the work. As a result, lawyers work hard to obtain settlements for their clients.

In some states, the settlement might include funds for pain and suffering, which is not a reimbursement for costs but a payment for the emotional stress experienced from the injury. Some states also allow for “punitive damages” if gross negligence or misconduct is involved. The amount allowed for such damages is often restricted. In the state of California, for example, no more than $250,000 can be awarded for non-economic damages.

When gross negligence or misconduct is involved, the local authorities might also bring a criminal action against the physician or medical facility. This action is separate from a medical malpractice case. In a criminal action, the plaintiff is the city or the state. A medical malpractice lawsuit is called a “civil” action, and the plaintiff in that case is the injured patient. Both the criminal and civil cases would have one or more defendants in common, however. The defendant is the person who is defending the claim – the party or parties who are alleged to have been medically negligent.

Note that only in cases of gross negligence does the health department take away a doctor’s medical license.

Do All Medical Negligence Cases Go to Trial?

Most of these cases are settled out of court, but when the parties cannot agree on a settlement amount, the case goes to trial. A judge or jury then makes the decision as to whether the patient is entitled to monies and how much. Before a case goes to trial, however, years of negotiations might pass. During that period, the lawyers for both sides prepare legal papers that answer the questions of the other party. These are called “pre-trial discovery” papers.

Depositions are also often taken of the parties. These are interviews that allow the opposing side’s attorneys to ask questions.

It is not unusual for a settlement to take place at the courthouse during the jury selection process. This is a tactic that pushes both sides against the wall, trying to coerce them to give in. The plaintiff wants the defendant to give in by offering more money in the settlement, while the defendant wants the plaintiff to give in by accepting the current settlement offer. No one ever wants to take a case to trial if it can be helped because the costs of court are much higher than out-of-court settlements.

The Right Prescription to Prevent Medical Identity Theft

What do you do with your empty prescription bottles? What about all of the medical information you receive, such as your explanation of benefits? Being careless with your personal medical information can be dangerous, and the theft of this priceless data can be deadly.

Approximately 1.5 million Americans are victims of medical identity theft each year, a crime that costs the nation $41.3 billion annually. Prescription fraud is a growing form of medical identity theft that is not only extremely costly and time-consuming; it can also put your health at risk and even be life-threatening. Unfortunately, medical identity theft isn’t commonly known by many Americans, and often isn’t detected until it’s too late. When we don’t take precautions to prevent prescription fraud and other forms of medical identity theft, we put ourselves in jeopardy of becoming another victim.

What is Prescription Fraud?

Prescription fraud occurs when identity thieves use your personal information to fill prescriptions in your name. They use your medical identity to receive medical treatment at hospitals and doctors’ offices, obtain medications, and access other healthcare services.

Prescription fraud doesn’t just leave you with a huge bill-it can potentially put your health at risk as well. You may find that false information has been added to your personal health record, such as a change in blood type or supposed allergies. Every medical procedure received and prescription filled by the identity thief becomes part of your medical history, which means you may not be able to obtain the life-saving treatment you need in an emergency medical situation.

Detecting and resolving medical identity theft can be difficult as well. You may not discover that you’re a victim until a pharmacy refuses to fill a prescription because it conflicts with another medication you appear to be taking. To make matters worse, fixing errors in your record can be very challenging due to medical privacy laws. Ironically, the same laws that were implemented to protect your privacy and health information are now protecting the medical identity thief. This restricted access to medical records prolongs the duration of the theft, costing you countless time, money, and frustration.

How to Prevent Prescription Fraud

One of the easiest ways to avoid this type of medical identity theft is simply to be aware of what you throw in the trash. Prescription medication labels carry such sensitive information as your full name and address, the prescribing physician, the type of medication, prescription number, and the pharmacy’s contact information-all of the things a thief needs to perform prescription fraud. Instead of throwing empty prescription bottles in the trash, including the drug information forms, remove the labels and shred them. Other ways to prevent prescription fraud:

• Review every explanation of benefits (EOB). Examine the charges for medical visits or prescriptions you didn’t receive, and report any suspicious activity immediately.

• Never simply toss medical information in the trash. Dumpster divers can easily access your personal information if you fail to shred the documents.

• Secure medical records. Keep your medical records in a safe place inside your home or in a safe deposit box, away from the prying eyes of visitors. Believe it or not, friends and relatives who have easy access to your personal information are often the culprits.

• Safeguard prescription bottles. Hide or lock-up your medication rather than leaving it in plain sight or in a medicine cabinet. This will prevent anyone from walking off with your prescription medication and, later, your identity.

• Manage written prescription slips. Don’t throw them away or leave them out where they can be stolen. These slips are all an identity thief needs to fill a prescription in your name, leave you without your medication, steal your medical identity, and even put your life in danger.

• Enlist the help of an identity theft protection service such as ID Theft Solutions, which can proactively help prevent medical identity theft and even restore your identity when it’s stolen.

Protecting your identity is an ongoing process that takes vigilance. By taking some common sense precautions, you can avoid the exorbitant costs and health risks of medical identity theft.

Why Is a Professional Medical Coder Important to Medical Billing?

Medical coding professionals have a key role to play in the medical billing process. Every time a patient receives treatment, accurate codes have to be assigned to each service or procedure. It is these codes that determine how these services will be billed. Seeking the support of a professional and certified medical billing company ensures that your coding is done accurately for faster reimbursement.

The primary responsibility of the medical billing team is to see that the services rendered by a healthcare provider are properly billed. The medical coding professional interprets medical reports, summarizes the information available in the documentation, assigns them appropriate codes, and develops the claim for submission.Medical coding involves the use of a system of alphanumeric codes determined by American Medical Association. These codes describe various medical, surgical, and diagnostic services. It’s very important that the medical coder interprets the medical report accurately to assign the right codes. This will determine the amount of reimbursement. Therefore accuracy in coding is crucial for proper claim reimbursement.

A professional medical coder would have a comprehensive knowledge of anatomy and medical terminology. Medical coders should also be familiar with and up-to-date on different types of insurance plans, government policies and, of course, CPT, ICD-9-CM, and HCPCS codes and guidelines. It is this knowledge that allows the medical coder to assign appropriate codes for the procedures that were performed and to provide the medical billing staff with the information necessary to process a claim for reimbursement.

The following points highlight the importance of a professional medical coder in the medical billing process.

    • Assigns suitable charges – Assigning of charges to resources that have been utilized in patient care. Narrative text is assigned to a code with an appropriate charge.
    • Establishes medical indispensability of treatment – Medical coding helps to confirm that treatment is medically necessary. Supportive documentation would make clear what kind of services were provided. This would facilitate assignment of appropriate codes to explain why treatment was required.
    • Facilitates insurance reviews – Insurance companies regularly carry out reviews to ensure the validity of charges. Supportive coding documentation enables insurance companies to comprehend why particular charges were submitted.
    • Provides precise reimbursement – Medical coding acts as the prime source for precise service reimbursement. Appropriately assigned medical codes are collected together to inform the insurance payer about the treatment provided to the patient so that compensation can be made.
  • Helps with appeal denials – Some times payers reject medical claims if they believe treatment was not required or if the claims were wrongly coded. In such a scenario, healthcare providers get an opportunity to appeal the compensation denials by putting forward supportive coding documentation that explains why particular codes were allotted for compensation.

It is therefore clear that medical billing and coding are inextricably linked. Only professional medical coders can ensure a fruitful medical billing process.