CurrentprominencehealthfirstoffloridaPolicy COMP.RM.001

Internal Risk Management Program

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Establishes Prominence HealthFirst's internal risk management program governing incident identification, reporting, investigation, and corrective actions across Prominence Health Plan lines of business and facilities in states where it operates.

Policy Summary

Payerprominencehealthfirstofflorida

PolicyInternal Risk Management Program

Policy CodePolicy COMP.RM.001

Change TypeNo material changes

Effective DateAug 1, 2018

Last ReviewJan 21, 2021

Next Review DateJun 1, 2022

Key ActionReport incidents to the Risk Manager within 3 calendar days and forward never-event determinations for payment denial to the Director of Operations.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3 daystimeframe to report incidents to risk manager

15 daystimeframe to report Code 15 incidents to AHCA

3 yearsretention period for summary incident data

1 hrannual training (nonphysician clinical staff)

Incident Reporting and Management Criteria

Incident reporting and management criteria

Requirements for incident reporting, investigation, and regulatory notification include:

Incidents must be reported to the Risk Manager (Manager of Compliance & Risk Management) within 3 calendar days; staff have the ability to report incidents to the Risk Manager.

Reportable incidents to the Florida Agency for Health Care Administration (AHCA) using Form 3140-5001 'Code 15' must be reported within 15 calendar days of occurrence; certain severe incidents require an initial 3-working-day notice and a 10-day detailed follow-up as applicable to AHCA reporting timelines.

Incident reports must be on a facility form and include at least: patient identifiers (name, locating information, admission diagnosis, admission date, age, sex); a clear concise description including time, date, exact location; elements needed for the annual report (e.g., ICD-10-CM elements); whether a physician was called and recommendations; listing of persons involved and witnesses with locating information; name, signature, position, date and time of the reporter; and supporting documentation.

The Risk Manager is responsible for investigation and documentation of incident findings and must forward findings to the Medical Director and/or Director of Health Services for review and final determination.

If the Medical Director and/or Director of Health Services determines the case meets the definition of a 'never event,' the determination to deny payment to the facility/provider is forwarded to the Director of Operations for payment effectuation and adjudication.

The Risk Manager shall regularly and systematically review incident reports (including 15-day reports) to identify trends or patterns and develop recommendations for corrective actions and risk management education and training as needed.

Summary incident data shall be maintained for 3 years and summary reports shall be provided to the governing body at least quarterly or more often as required; documentation shall be available to authorized Agency representatives upon request.

New employees must be instructed about the incident reporting system and their responsibilities within 30 days of employment; at least annually, all nonphysician clinical personnel must receive a minimum of 1 hour of risk management and risk prevention education and training.

The incident reporting system and this policy apply to Prominence Health Plan lines of business (including Commercial and Medicare) and to incidents associated with employees, patients, visitors and family members.

Incident Reporting Elements (Coding)

Incident reporting elementsICD-10

ICD-10-CM

Incident elements may be based on ICD-10-CM for annual reporting

Provider Billing and Denial Guidance

Denial Risk

Payment denial for never events

If the Medical Director and/or Director of Health Services determines the case meets the definition of a "never event," the determination to deny payment to the facility/provider is forwarded to the Director of Operations for payment effectuation and adjudication.

Risk Manager investigates and documents incident findings and forwards to the Medical Director/Director of Health Services for review prior to denial determination.
Payment denial decisions for confirmed 'never events' are then sent to the Director of Operations to effectuate and adjudicate the payment denial.

Key Definitions

CMS definition — 'Never Events'

DefinitionCMS defines 'Never Events' as non-reimbursable serious hospital-acquired conditions that are unambiguous (clearly identifiable and measurable), usually preventable, and serious (resulting in death, loss of a body part, disability, or more than transient loss of a body function).

Attributes - UnambiguousEvents are clearly identifiable and measurable, making them feasible to include in a reporting system.

Attributes - Usually preventableRecognizes that most events are preventable while acknowledging some may not be avoidable due to health care complexity.

Attributes - SeriousIncludes outcomes such as death, loss of a body part, disability, or more than transient loss of body function; also adverse events indicative of a safety system problem or important for public credibility/accountability.

Florida statute s. 641.55 — reportable incidents and timelines

Statute referencedFlorida Statute s. 641.55 defines 'adverse or untoward incidents' that must be reported to the agency.

Reportable incidents — examplesIncidents that result in patient death; severe brain or spinal damage; a surgical procedure performed on the wrong patient; or a surgical procedure unrelated to the patient's diagnosis or medical needs.

Initial reporting timeframeThe organization must report the incident to the agency within 3 working days after its occurrence.

Follow-up reporting timeframeA more detailed follow-up report must be submitted to the agency within 10 days after the first report; the agency may require an additional final report.

Policy Summary

Payerprominencehealthfirstofflorida

PolicyInternal Risk Management Program

Policy CodePolicy COMP.RM.001

Change TypeNo material changes

Effective DateAug 1, 2018

Last ReviewJan 21, 2021

Next Review DateJun 1, 2022

Key ActionReport incidents to the Risk Manager within 3 calendar days and forward never-event determinations for payment denial to the Director of Operations.

SourceLink

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Internal Risk Management Program

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Incident Reporting and Management Criteria

Incident reporting and management criteria

Requirements for incident reporting, investigation, and regulatory notification include:

Incidents must be reported to the Risk Manager (Manager of Compliance & Risk Management) within 3 calendar days; staff have the ability to report incidents to the Risk Manager.

Provider Billing and Denial Guidance

Denial Risk

Payment denial for never events

Risk Manager investigates and documents incident findings and forwards to the Medical Director/Director of Health Services for review prior to denial determination.
Payment denial decisions for confirmed 'never events' are then sent to the Director of Operations to effectuate and adjudicate the payment denial.

Key Definitions

CMS definition — 'Never Events'

Attributes - UnambiguousEvents are clearly identifiable and measurable, making them feasible to include in a reporting system.

Attributes - Usually preventableRecognizes that most events are preventable while acknowledging some may not be avoidable due to health care complexity.

Florida statute s. 641.55 — reportable incidents and timelines

Statute referencedFlorida Statute s. 641.55 defines 'adverse or untoward incidents' that must be reported to the agency.

Initial reporting timeframeThe organization must report the incident to the agency within 3 working days after its occurrence.

Follow-up reporting timeframeA more detailed follow-up report must be submitted to the agency within 10 days after the first report; the agency may require an additional final report.