Risk Management

Part-time and Multi-state Practices

By Betsy Kelley, OMIC Underwriting Manager

[Digest, Fall, 2002]

In response to changes in the marketplace, adverse loss development, and concerns about rate adequacy, OMIC has thoroughly reviewed its rating structure and discount plans, including those pertaining to part-time and multi-state practices. Discounts still will be offered to qualified part-time surgeons in recognition of their reduced practice activities; however, stricter guidelines are being imposed to determine eligibility for this discount. Effective immediately for new insureds and upon renewal for existing insureds, physicians must meet the following criteria in order to be eligible for a part-time surgical discount:

-The physician must practice fewer than 20 hours per week.

-The physician must perform fewer than 100 surgeries annually (fewer than 50 if practicing less than 10 hours   per week).

-The physician may not perform any retina surgery, refractive surgery, or cosmetic oculoplastic surgery.

Because of the increased liability exposure and differences in legal climate among states, OMIC determined that changes in its multi-territory rating are also needed. While previously physicians could practice up to 25% in a higher rated territory without it affecting their premium, physicians now will be charged the higher territory if they render services in that territory.

Refractive Surgery

In response to inquiries by current and potential insureds, the Underwriting Committee met in September to review the guidelines for refractive surgery. Because of the possibility that the guidelines with respect to preoperative care could be misinterpreted, the committee modified the guidelines to be more specific with respect to the surgeon’s obligations to the patient. Prior to surgery, the surgeon must perform and document and independent evaluation to determine the patient’s eligibility for surgery. As part of the independent evaluation, the surgeon must personally examine the patient’s eyes and ocular adnexa, perform a slit lamp exam, and carefully review topographies, pupil size, pachymetry, refractive stability, eye health history, and prior records. In addition, the surgeon must carefully analyze the patient’s expectations and, when appropriate, discuss monovision.

The committee also agreed to eliminate the requirement that there be a minimum interval of three months between primary PRK/LASEK/Intralase procedure and reoperation. Enhancements may be performed as soon as the patient’s refraction has been stable (i.e., not more than a one-half diopter change) for at least two months and the residual error is at least 0.75 D.

Intacs for Keratoconus

The committee also adopted underwriting guidelines to review and approve qualified physicians for the off-label performance of Intacs procedures on keratoconus patients. Such patients much be contact lens intolerant, have clear central corneas, have corneal thickness of 450 microns or more at the sides of the segments, and have only PKP as an option to improve vision. They must be informed that the procedure is likely to only temporize the progression of the cone and that they may need a PKP for definitive therapy. The off-label and temporizing nature of the procedure must be documented in the consent form and medical records.

Cosmetic Botox

OMIC has formally adopted underwriting guidelines for the performance of cosmetic Botox procedures. These guidelines are quite similar to those issues addressed in Paul Weber’s Risk Management Hotline article, “Managing the Risks of Botox,” (OMIC Digest, Summer 2002). The guidelines cover a variety of issues, including training, patient selection, documentation, informed consent, practice patterns, and advertising. OMIC also requires that Botox be administered only in appropriate medical settings.

Pain Management at Surgicenters

For several years, OMIC has extended coverage to ophthalmology-owned surgery centers used by other specialties. Some of these insured surgery centers either currently allow or are interested in allowing pain management specialists to perform pain management procedures at their facilities. With the assistance of the Physician’s Insurer’s Association of America, OMIC researched this issue and found that there have been several extremely large verdicts and settlements of claims involving pain management. Data provided by the American Society of Anesthesiologists offered further evidence of the increased liability exposure of these procedures and also indicated that pain management claims are generally difficult to defend and frequently involve issues with documentation deficiencies and inadequate consent.

As a result of these concerns, the company has determined that it is no longer in a position to insure surgery centers at which pain management procedures are performed. Existing insured facilities will be offered sufficient time to phase out the performance of pain management procedures or to secure coverage through another carrier.