Term Paper Health Care Law

Topics: Risk management, Health care, Insurance Pages: 12 (2280 words) Published: April 15, 2015
Running head: Legal Risk Management and the Clinical Utilization Review Process 1

Legal Risk Management and the Clinical Utilization Review Process

Celia Gomez
Wayland Baptist University
HLAD 5337 – Vco1 Health Care Law
Dr. Lloyd L. Cannedy, Ph. D.
October 01.2012

Legal Risk Management and the Clinical Utilization Review Process 2

Abstract

Use the text book, case studies and other references to determine the history and process of Legal Risk Management and the Clinical Utilization Review Process. It will identify weaknesses and strong points of the current Clinical Utilization Review Process. It will address Legal Risk Management in the early years and the statistics and growth of Managed Care and the restructuring of Managed Care. It will explore the legislative and regulatory decision including debates surrounding the Legal Risk Management and the Clinical Utilization Review Process. It will explore the purpose of the medical review process and the impacts medical decision making has on patients. Finally it will cover the goals of the medical review process and quality management to end with a conclusion.

Legal Risk Management and the Clinical Utilization Review Process 3

Legal Risk Management and the Clinical Utilization Review Process An Overview of Risk Management

The Legal Risk Management process is nothing new for the health care industry nor is it a new social or legal ordained program. In fact as early as four thousand years ago the Babylonian Code implemented severe punishment to physicians that caused death or harm to patient through their own malpractice. Law wrote: “should a physician operate on a man with a bronze lancet and cause a man’s death, they shall cut off his fingers”. In the 1970’s began a large upward movement in malpractice suits creating a crisis situation for physicians and the health care industry as whole. As a result of these huge numbers of dollars in law suits the health care industry and affiliates employed risk management personnel and designed a program to prevent adverse patient outcomes known as (APOs). This process ignited focusing on the health organization bottom line and Ronald J. Guilfoile risk manager in St. Paul saved the health care organization an astounding $20 million dollars in lawsuit prevention. ****

In definition Risk Management is a coincided effort to identify, assess and reduce risks to patients, visitors, staff and organizational assets. It is a program to Legal Risk Management and the Clinical Utilization Review Process 4

reduce preventable accidents and injuries and prevent the financial loss to the health care organization should an accident or injury occur. This definition can be further dissected to read Risk Management is the process to where a covered patient is entitled to receive all health care services stipulated under contract no more or no less to include the most cost effective level possible by reducing accidents that can lead to injury to all personnel involved and covered.

The Risk Management Process

The Risk Management Process is quit simple and Risk Management personnel have one goal in sight. Let’s call this goal the four step progression this will include: risk identification, risk analysis, risk control and risk financing. This process will identify exposures that may interfere in a health care organization’s goals and bottom line. This includes the 5i system which measures five steps: 1. Investigate: study and examine by close examination and systematic inquiry. 2. Inform: introduce in material form.

3. Influence: affect or alter by indirect or intangible means. ***** 4. Interpret: explain the meaning of present in understandable terms. 5. Integrate: blend into a whole and combine it with something else.

Legal Risk Management and the Clinical Utilization Review Process 5

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