Risk management program

An event, as defined in Chapter 395.0197(5) of the Florida statutes, over which provider could exercise control, which is more probably associated, in whole or in part, with the medical intervention rather than the medical condition for which such medical intervention occurred, and which results in one of the following:

1. Death
2. Brain or spinal damage
3. Permanent disfigurement  
4. Fracture or dislocation of bones or joints 
5. A resulting limitation of neurological, physical, or sensory function which continues after discharge from the facility  
6. Any condition that required specialized medical attention or surgical intervention resulting from non-emergency medical intervention, other than an emergency medical condition, to which the member has not given his/her informed consent; or 
7. Any condition that required the transfer of the member, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the member’s condition prior to the adverse incident, including:
   
   
   1. The performance of a surgical procedure on the wrong patient, a wrong surgical procedure or wrong-site surgical procedure, or a surgical procedure otherwise unrelated to the member’s diagnosis or medical condition 
   2. Required surgical repair of damage resulting to a member from a planned surgical procedure where the damage was not a recognized specific risk, as disclosed to the Member and documented through the informed consent process
   3. A procedure to remove unplanned foreign objects remaining from a surgical procedure; or
   4. Any complaint or allegation of sexual misconduct and abuse or contact by provider employee or agent of provider.

If an adverse or untoward incident occurs to a member, provider shall report the adverse or untoward incident (as defined under Florida law) to the Plan’s risk manager within twenty-four (24) hours after its occurrence. Provider shall

1. Participate in and cooperate with the Plan’s risk management program;
2. Provide such medical and other records without charge within ten (10) days of receipt of written notice; 
3. Share such investigation reports and other information as may be required or requested by the Plan’s risk manager to determine if an adverse or untoward incident is reportable as a “Code 15” to AHCA; and 
4. In all other respects comply with and abide by the provider manual. A provider’s failure to comply with these requirements may be deemed a material breach of the agreement, at the Plan’s sole discretion.

When an incident occurs: 

• Complete the incident report form (PDF) (located in our Aetna Better Health® of Florida website) 
• immediately upon becoming aware of an adverse or untoward incident. 
• Fill each blank on the form, using N/A when not applicable to the particular occurrence. 
• Write legibly or type the information on the form. 
• Describe the incident carefully. Be brief, but include important information, including who, what, where, when, and how of the event/situation. 
• Indicate the body part injured, the location and extent of injury and document fully, including lack of injury. 
• Report any pertinent action taken in response to the occurrence. 
• Obtain the name and location information for any witnesses, including employees. 
• Sign and date the report. Include title/designation and contact phone number. 
• Fax to the Aetna Better Health of Florida Risk Manager at 1-877-479-8564. 

For assistance in completing the incident report form, contact our Risk Manager at 954-858-3246. 

Incident reports are part of risk management files only and copies of incident reports must be maintained separately from member’s medical records. 

All incident reports will be reviewed, and date stamped upon receipt. Appropriate action will be initiated when indicated. Incident reports will not be used to penalize providers; however, failure to report an adverse or untoward incident may result in further action.

Providers shall implement a systematic process for incident reporting. Providers will notify Aetna Better Health of Florida within 24 hours of an occurrence of an incident that may jeopardize the health, safety, and welfare of a member or impair continued service delivery. Licensed facilities must provide notification within 15 days in accordance with Florida Law 400.147, 429.23, Section 39 and Section 415, 

Reportable conditions include but are not limited to: 

• Closure of provider locations or facilities due to license violations 
• Provider financial concerns/difficulties 
• Loss or destruction of member records 
• Compromise of data integrity 
• Fire or natural disasters 
• Critical issues or adverse incidents that affect the health, safety, and welfare of members

In the member’s record, the provider will contain a brief summary of the problem(s) and proposed corrective action plans and timeframes for implementation within a reasonable time after the incident is reported. 

Provider will inform Aetna Better Health of Florida within 30 days of the occurrence date, using a secure process (secure email) for proper handling of HIPAA related information. 

Providers will also report adverse events involving our Long-Term Care (LTC) members to the LTC Case Manager and assist the Case Manager with the review. Such adverse events would include the following: 

• Adverse events required by rule or law to be reported to regulatory authorities such as neglect, abuse, exploitation, and fraud 
• Adverse events related to the following: 
  
  
  • Decline in management of medications 
  • Significant worsening of ADLs 
  • Significant change in toileting ability 
  • Falls or accidents(with or without injury) 
  • Disaster that leaves provider facility diminished 

All adverse event reporting and reviews are part of the quality initiatives for both Aetna Better Health of Florida and the provider. This quality initiative and risk management process anticipates the information will not be included in the discoverable elements of the member file.