1. Five Pillars – Malpractice Insurance Claims Review Mario T. Catalano, DDS, MAGD, FACD

2. @ASDAnet #ASDAnet 1.National Carrier 2.Financial Strength 3.Policy Limits 4.Occurrence or Claims-Made 5.Consent to Settle Clause Five Pillars of Quality

3. @ASDAnet #ASDAnet 1. National Carrier Overview: Freedom of movement – now have licensure by credentials in 46 states Relocation – Seamless transition process when moving to another state Claims experience in all jurisdictions Stable pricing – not subject to sporadic pricing fluctuations because of increase in frequency/severity in one or two states

4. @ASDAnet #ASDAnet Overview: www.A.M.Best.com- unbiased rating agency for all insurance companies:www.A.M.Best.com- o Highest rating possible is A++ At least 16 companies have left the dental market in the last 15 years: o Quality of defense is directly proportional to the financial status of a company Specialty companies tend to be isolated from external forces 2. Financial Strength

5. @ASDAnet #ASDAnet Per claim / Per policy year Industry StandardTrending Standard $1 million / $3 million$2 million / $4 million Other Options $3 million / $5 million $4 million / $6 million $5 million / $7 million 3. Policy Limits

6. @ASDAnet #ASDAnet Overview: CA dentist enrolls in program teaching sophisticated full mouth rehabilitation Treatment modalities seem very obvious Dentist begins to have many implant and cosmetic failures Abandons the program and is unsuccessful in completing the cases 14 malpractice cases are filed against the doctor in one year 3. Policy Limits – Case 1

7. @ASDAnet #ASDAnet Result: The dentist has a $1M/$3M claims-made policy The dentist has $3M in total coverage for the 14 cases First three cases settle in excess of $1M: o Cases of multiple implant failures o Require additional surgical procedures o Plaintiff friendly jurisdiction (Los Angeles) Limits possibly exhausted – doctor may have to pay indemnity out of own pocket 3. Policy Limits – Case 1

8. @ASDAnet #ASDAnet Overview: 63 y/o disabled male presents with chief complaint of chipped porcelain on tooth number 9, a bridge pontic, and requires replacement of mandibular posterior teeth Patient is seen and evaluated by a dental assistant/treatment coordinator She recommends replacement of maxillary bridge for a cost of $21,000 3. Policy Limits – Case 2

9. @ASDAnet #ASDAnet Patient returns 1 month later - meets with dentist: o Informs patient that he has TMD and requires treatment (appliance and TENS) - Cost of $8000 Patient’s wife balks at treatment plan/cost - dentist embarrasses spouse into accepting: o Exaggerates need for TMD treatment: o Questions husband’s future ability to eat 3. Policy Limits – Case 2

10. @ASDAnet #ASDAnet Dentist provides Neuromuscular therapy and replaces bridge from 3 to 14 - “decay and abfractions” Root canal therapy required on 3, 4 & 13 7 months later – fixed bridge on 12 to 14 shears off at gumline: o Bridge removed - graft and immediate implants placed in 12, 13 & 14 3. Policy Limits – Case 2

11. @ASDAnet #ASDAnet 1 month later- upper bridge breaks, number 4 is removed, and the bridge is recemented Patient seen by associate - crowns placed on 21, 22 & 23 Dentist places crowns on 12, 13 & 14 Implant supported crowns crack the new crowns on 21 & 22 Price Tag - $43,000 3. Policy Limits – Case 2

12. @ASDAnet #ASDAnet Patient sees another dentist who removes Neuromuscular orthotic because there are no signs or symptoms of TMD Upper right bridge fails: o Upper anterior bridge has decay noted on all abutments o Both are removed and replaced with an upper removable appliance 3. Policy Limits – Case 2

13. @ASDAnet #ASDAnet Patient referred to an OMFS for failing implants: o Implants removed o Extensive bone grafting of maxilla is accomplished and additional treatments are planned for implants Patient institutes a malpractice action State Board for Dentistry removes dentists license 13 additional cases ensue after information is made public 3. Policy Limits – Case 2

14. @ASDAnet #ASDAnet Result: $43,000 – Total spent by patient $46,000 - Corrective grafting and implant placement cost $23,000 - Maxilla restoration cost $5,000 - Cost to restore mandibular arch $115,000 – Estimated cost of rework Sympathetic Jury - Patient is disabled and has income of $1500/month $348,000 – Cost of settlement in case 1 of 14 3. Policy Limits – Case 2

15. @ASDAnet #ASDAnet Overview: New dentist buys practice from retiring dentist Patient of retiring dentist presents with a potential implant infection of a mandibular overdenture supported by 4 implants Young dentist removes the overdenture to evaluate During overdenture removal, the patient coughs, and the young dentist drops the hex tool into the patient’s throat 3. Policy Limits – Case 3

16. @ASDAnet #ASDAnet Overview Continued: Patient is raised in the chair: Patient swallows the tool after unsuccessful removal Ambulance called and patient is taken to hospital 3. Policy Limits – Case 3

17. @ASDAnet #ASDAnet 3. Policy Limits – Case 3

18. @ASDAnet #ASDAnet X-ray taken at ER - Implant tool in patient’s stomach Gastroenterologist consulted and recommends removal of the tool During the removal procedure, the patient’s esophagus is perforated A trauma surgeon is called, and he performs surgery to repair the tear Patient loses significant portion of voice Patient develops swallowing problems 3. Policy Limits – Case 3

19. @ASDAnet #ASDAnet Patient’s health deteriorates: o 10 months later she suffers a stroke: o Requires a feeding tube Surgery performed to recover patient’s voice: o 1 month later, patient suffers second stroke: o Partial paralysis o 6 weeks later, while the husband is mouth feeding the patient sans feeding tube, the patient aspirates a bolus of food and dies 3. Policy Limits – Case 3

20. @ASDAnet #ASDAnet Result: Husband files a malpractice lawsuit on behalf of deceased wife Plaintiff attorney’s expert witness concludes that the dentist should have taken precautions to prevent the swallowing of the implant instrument $ 3,500,000 – Demand in wrongful death lawsuit $1,000,000 – Final settlement 3. Policy Limits – Case 3

21. @ASDAnet #ASDAnet Considerations: Nature of practice and specialty Location of practice: o Rural, urban, or suburban Scope of services provided: o Extractions, Implants, IV Sedation? Personal risk tolerance 3. Policy Limits - Review

22. @ASDAnet #ASDAnet Occurrence and Claims-Made Most quality insurers offer both Companies prefer the risk associated with the claims-made policy Insured’s are better covered with an occurrence policy 4. Coverage Options

23. @ASDAnet #ASDAnet Coverage options: Occurrence or Claims-Made 4. Coverage Options

24. @ASDAnet #ASDAnet Overview: Dentist performs extractions of teeth 15 & 16 Patient has a difficult post-op healing period, which includes post-op swelling and pain 1 month after the event, the dentist has a disciplinary hearing regarding a substance abuse charge - License is suspended 4. Coverage Options – Case 4

25. @ASDAnet #ASDAnet Dentist enters into rehab and hires a Locum Tenens (LT) dentist to cover his practice while he is gone The LT dentist sees the patient 2 months after the original procedure: o Diagnoses the problem as possible sinusitis and refers patient to her PCP: o PCP prescribes a regimen of Cipro 4. Coverage Options – Case 4

26. @ASDAnet #ASDAnet 1 month later – Patient still having problems and presents to the practice with swelling in the 14 area and sees a different LT dentist who performs root planning 3 days later – Patient has pain and swelling, prescribed clindamycin 4. Coverage Options – Case 4

27. @ASDAnet #ASDAnet 4 days after the last appointment - Patient still in pain, LT dentist extracts tooth 14 due to a periodontal infection 2 days later - Patient has overt drainage, and is referred to an OMFS OMFS examines patient and removes tooth 13, debrides the tooth 14 area, and adds Z-pak to the clindamycin regimen 4. Coverage Options – Case 4

28. @ASDAnet #ASDAnet 4 days later - Patient discontinues medication, because they were making her nauseous OMFS tries to see the patient for a follow-up appointment: o Patient was feeling so poorly that she cancelled the appointment 13 days later – Patient presents to the ER with a diagnosis of sepsis and septic shock 4. Coverage Options – Case 4

29. @ASDAnet #ASDAnet Patient’s husband is very angry - Notifies both the original dentist and the OMFS that he intends to sue them all The LT dentists are both notified of the potential claim 4. Coverage Options – Case 4

30. @ASDAnet #ASDAnet How does coverage type impact these Locum Tenens dentists? The first LT dentist had intentions of moving back to the west coast, which is why she was working as a LT When she contacted a west coast carrier, she was obligated to discuss the potential claim 4. Coverage Options – Case 4

31. @ASDAnet #ASDAnet Coverage and Locum Tenens: If she has a claims-made policy, this could be a problem If she has Occurrence coverage, no problem at all If she has a national carrier, again no problem 4. Coverage Options – Case 4

32. @ASDAnet #ASDAnet Considerations: Point in career Possibility of returning for additional training Possibility of family leave Possibility of career change Possibility of changing mode of practice Possibility of retirement 4. Coverage - Review

33. @ASDAnet #ASDAnet What is consent to settle? Your rights, duties, and obligations regarding settlement of a malpractice claim 5. Consent to Settle

34. @ASDAnet #ASDAnet Pure Consent: “ We will not settle a claim without your consent” Some companies say they would never settle without your consent, but pure consent is not written into their policy o Ask them to put it in writing Just as with a dental record…if it isn’t in writing, then it doesn’t exist 5. Consent to Settle

35. @ASDAnet #ASDAnet Overview: 29 y/o male patient presents to a young dentist who is an associate in a general practice The tooth, which had a previous root canal treatment, was diagnosed with a fractured root - extraction recommended Patient filled out a general informed consent form prior to anesthetization and tooth removal 5. Consent to Settle – Case 5

36. @ASDAnet #ASDAnet Overview Continued: Due to the difficult nature of the extraction, a small piece of the mesial buccal root became separated: o Removed using rotary instruments A post-op X-ray was taken and the young doctor was satisfied that the entire tooth had been removed 5. Consent to Settle – Case 5

37. @ASDAnet #ASDAnet 5. Consent to Settle – Case 5

38. @ASDAnet #ASDAnet 5. Consent to Settle – Case 5

39. @ASDAnet #ASDAnet Post-op Complications: The patient did not experience an unusual amount of bleeding or discomfort 3 days post-op, the patient experienced a yellow brown discharge from his right nostril He contacted the dentist, because he also thought he was having an odor from the extraction site 5. Consent to Settle – Case 5

40. @ASDAnet #ASDAnet Post-op Complications Continued: The dentist, suspecting a sinus perforation, referred the patient to an OMFS The OMFS instituted treatment and repaired the sinus - the healing was unremarkable 5. Consent to Settle – Case 5

41. @ASDAnet #ASDAnet Considerations: Future mobility Future insurability Peace of mind State board actions You pay for it 5. Consent to Settle – Review

42. @ASDAnet #ASDAnet Thank you! Mario T Catalano DDS MAGD FACD MTCatalano@Aol.com Five Pillars of Quality