Risk Management

Poor Results from Bilateral Upper Lid Blepharoplasty

Digest, Winter, 1993

ALLEGATION  Insured ophthalmologist allegedly failed to advise claimant to discontinue use of an antiplatelet medication prior to surgery. Additionally, there were allegations of failure to obtain proper informed consent and failure to refer to a plastic surgeon.

DISPOSITION  Settled with indemnity payment for subsequent repair surgery.

Case Summary

The patient was a 55 year-old male. A short-term patient of the insured ophthalmologist, he presented with ptosis and dermatochalasis OU, and elected to have a bilateral upper lid blepharoplasty. Visual acuity was not a significant factor. The risks and complications were discussed, and informed consent obtained. Past medical history revealed the patient had been on antiplatelet therapy due to a history of circulatory impairment.

Two days postoperatively, the patient demonstrated excessive swelling and ecchymosis below OU. He had not applied ice postoperatively and had not stopped taking his antiplatelets pre or postoperatively. One month later, the patient still demonstrated swelling of the lower lids and discoloration. At his six-month postoperative exam, a second opinion was obtained from a plastic surgeon who was critical of the insured’s surgery.

By this time as well, the patient’s health insurance carrier had denied coverage of the surgery on the grounds that it was elective in nature and did not meet the guidelines of medical necessity. Dissatisfied with his outcome, the patient refused to pay the insured and efforts on the part of the office staff to collect prompted the patient to seek an attorney.

Outcome

In reviewing the records, it became evident that there were documentation deficiencies which impeded the defense. There was no indication that the ophthalmologist had advised the patient to discontinue the antiplatelet preoperatively. Continuing the antiplatelet delayed postop healing. The operative report indicated a manipulation of the lacrimal glands which, according to claimant’s counsel, had not been discussed in the informed consent process. These factors, coupled with the bill dispute, led the insured to consent to settle the claim, which included compensation for the claimant’s “second repair surgery” with improved results.

Risk Management Principles and Commentary

Patient dissatisfaction with the result does not necessarily obligate the surgeon to compensate the patient. Each case warrants evaluation of its own merits. Often, oculoplastic procedures do not meet the medical necessity criteria for third-party reimbursement. This, combined with the risk of imperfect results, can strain the physician-patient relationship.

The following risk control measures on the part of the ophthalmologist and staff may help prevent or reduce the severity of a claim:

• Although an ophthalmologist’s focus is specific, a complete review of systems and discussion of medical history should be part of the patient’s medical record.
• A thorough discussion of the procedure as well as photos taken prior to surgery (preferably as part of the informed consent process) may be prudent, particularly when the surgery may not meet “medical necessity guidelines.”
• A procedure- and patient-specific postop instruction sheet with a copy filed in the medical record undermines the credibility of a patient who claims “ignorance” following a bad result. If the hospital provides the instruction sheet, as is often the case, the ophthalmologist should add any specifics relevant to that patient’s medical history.
• Continued rapport between ophthalmologist and staff and the patient is important, particularly with dissatisfied patients. Avoiding “difficult” patients only fuels the situation. A “no-charge visit” to discuss options with the dissatisfied patient may preclude the costs associated with the filing of a claim. If there is difficulty establishing rapport with the patient from the outset, it may be a cue to the physician to recommend a second opinion.
• Finally, bill abatement or adjustment may be considered. This is not necessarily an admission of liability, but rather a courtesy gesture and should not be practiced as a general rule. However, if the facts of the case merit it, waiving the fee can go a long way toward averting or mitigating a claim.