HIROC Claims Management
Service: Claims , Risk Management
Subject: Risk Management Operations
Type: Risk Notes
Overview of Issue
Risk managers, or the person responsible for claims management in a healthcare organization, are able to manage liability, crime and/or commercial (such as property, equipment breakdown, and travel) claims as a means of loss control. Risk managers report incidents that may result or have resulted in a claim covered by insurance to HIROC in a timely way. They will build relationships with claims examiners, adjusters, and legal counsel to investigate and handle claims. Risk managers should know what claims have been put forth against the healthcare organization and their status.
Note: the term risk manager refers to anyone who has the authority to report claims to HIROC and/or insured registered midwives.
- Building effective relationships with HIROC claims examiners, adjusters and legal counsel will make the claims management process go more smoothly.
- Timely claim notification and assistance facilitates early investigation, preservation of evidence, and fair resolutions.
Things to Consider
Claim Reporting Process
- Risk managers need to be able to identify potential claims in a timely manner. This can often times be more of an art than a science. Risk managers also need to report actual claims (e.g. statements of claim, notice letters, etc.) as soon as they are served upon the healthcare organization. If a risk manager is unsure about whether to report, they should contact the Claims department at HIROC to discuss the matter.
- Risk managers must notify HIROC of all actual and potential claims. Timely notification of claims enables HIROC’s claims examiners, adjusters, and legal counsel to initiate an investigation when information is readily available and the details of the incident are still fresh in the minds of those involved. This allows for efficient and effective handling of the matter and promotes fair resolution.
- The Claim Reporting Process Frequently Asked Questions document, located on the HIROC website's member portal, guides organizations and registered midwives regarding what should be reported as a claim, how to report the claim, what should be included on the claim reporting form, and what happens after a claim is reported. Specific guidelines related to labour / delivery, infants and first party property losses are included.
Effective relationships with claims examiners, insurance adjusters and legal counsel
- Claims examiners instruct adjusters and legal counsel. All parties work with the risk manager in the investigation and further handling of actual and potential claims. Risk managers should understand the roles of the claims examiner, insurance adjuster, and legal counsel in order to meet each of their needs.
- Claims examiners are responsible for the overall management and disposition of matters reported to HIROC.
- Insurance adjusters investigate the details of matters reported to HIROC. They typically interview staff in the presence of the risk manager and possibly the staff member’s manager. Adjusters may, with the approval of HIROC, settle claims, close them, or hand them over to legal counsel.
- Legal counsel may be retained by the claims examiner to provide legal assistance for potential or actual claims. Discussions with legal counsel are protected by lawyer-client privilege. Legal counsel are typically retained in complex matters, or when legal proceedings have been initiated.
- Risk managers can build rapport with claims examiners, adjusters, and legal counsel by listening carefully, asking questions, giving notice (e.g. patient’s condition changes), being honest, anticipating and meeting needs, maintaining communications, and identifying system weaknesses.
- Once a claim is reported to HIROC, risk managers have an ongoing role in securing and collecting evidence, gathering information, identifying, and, if necessary, interviewing involved staff. This includes taking steps to preserve security camera footage. Risk managers may testify in legal proceedings.
- By being responsive to requests from claims examiners, adjusters, and legal counsel, risk managers can make the claims management process go smoothly. Common tasks include securing the patient chart; informing staff of dates for legal proceedings requiring their attendance; and (upon request from counsel) responding to undertakings from examinations for discovery.
- Risk managers are responsible for supporting staff throughout the claims management process. Risk managers should prepare staff to meet with the adjuster or legal counsel or to testify in a legal proceeding. Refer to HIROC’s Risk Note on Preparing Staff to Give Evidence.
- Risk managers may be called upon to be the hospital representative in an examination for discovery.
- Risk managers will be consulted by HIROC prior to settling a claim. The healthcare organization must authorize any compensation paid out in a HIROC claim. The risk manager may need to seek approval from senior leadership depending on the process at each healthcare organization.
- Risk managers should use the learnings from closed claims to mitigate risk at the healthcare organization.
- Healthcare organizations should have a policy to guide the risk manager or person responsible for claims management regarding the claims management process (e.g. process for accepting statements of claim, notification of insurer).
- The process of managing a claim may involve multiple meetings with different individuals who may have different reasons for meeting, e.g. the adjuster may ask staff initial questions about their involvement while another meeting with legal counsel may be required to understand new issues that have emerged in preparation for examinations for discovery. This is normal and should be expected.
Claims Tracking and Reporting
- Risk managers should track all actual and potential claims reported to HIROC to enable the organization/ risk manager to know, at any time, what claims are in progress and the status of each claim. Useful things to track include the patient’s unique identifier, patient/claimant’s name, incident date, date statement of claim received, date reported to HIROC, HIROC claim number, HIROC assigned claims examiner, adjuster, legal counsel, whether staff and/or physicians are named, and the status of the claim (e.g. examinations for discovery pending).
- It is also helpful to track the steps taken when a new actual or potential claim has occurred (e.g. Health Records notified to secure health record, meeting set with involved staff to inform them of action, determining if there is a related patient relations file). This could take the form of a checklist.
- HIROC. (2015). Claim reporting process. Frequently Asked Questions.
- Beach, C, Burgar, E, Slemko G. (2015). How to build an effective relationship with your adjuster and legal counsel [HIROC webinar].
- ECRI. (2014). The role of the healthcare risk manager: A primer. Healthcare Risk Control, 2