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Nurse practitioner Surani Hayre-Kwan discusses her article “Are you protecting your career? 5 essential questions about your NP liability insurance.” Surani discusses the critical need for nurse practitioners to secure their own professional liability insurance, highlighting how relying solely on employer-provided coverage can leave significant gaps. She provides insights into common pitfalls, such as employer policies often excluding licensing board complaints or having shared liability limits. Surani explains the crucial differences between occurrence and claims-made coverage and the importance of understanding “tail” and “nose” coverage to ensure continuous protection when switching jobs or carriers. She also offers actionable advice on how robust documentation, including adherence to SOAP note standards and careful patient engagement, can serve as a powerful defense against legal challenges. Surani emphasizes that comprehensive malpractice coverage is vital for protecting an NP’s license, career, and financial stability.

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Surani Hayre-Kwan. She’s a nurse practitioner and a member of The Doctors Company’s APC Advisory Board. Today’s KevinMD article is, “Are you protecting your career? Five essential questions about your nurse practitioner liability insurance.” Surani, welcome to the show.

Surani Hayre-Kwan: Thank you. Great to be here.

Kevin Pho: Before we talk about the article, briefly share your story and what led you to write it in the first place.

Surani Hayre-Kwan: I’ve always been pretty passionate about liability insurance. It started when I was a new grad nurse student. We had a lecture by an attorney who talked about all the risks that come in health care, and I thought I was going to carry my own liability insurance when I was a brand new nurse. It’s really not something that most nurses do, and that’s something that I’ve carried with me my entire career as I became a nurse practitioner.

I’m pretty passionate about the idea. I talk to people all the time about what liability and malpractice insurance actually mean. This particular story that I shared in the article was something that happened to a colleague of mine. I was just so shocked by how bad the outcome was that I knew that I had to share this with more people so they could perhaps think about their own potential risk and protect themselves before something happened.

Kevin Pho: Talk about that story that led your article off.

Surani Hayre-Kwan: My colleague had her own practice with a physician. They had a long-established practice taking care of patients in long-term care facilities. She would go see them, do all their assessments, write it up, et cetera. At some point, she made a decision to stop her malpractice insurance. I’m not going to get into all the reasons why, but she still had a couple of years of practice left. She thought, “I’ve never had anything happen.” She is very well respected in our community and actually nationally as well as an expert.

Unfortunately, there was a patient who had a bad outcome. It was a pretty standard end-of-life situation, but the wife was very upset. She didn’t spend a lot of time going to see her husband, and then when he did pass, she was pretty upset and ended up calling the medical board and filing a complaint.

The medical board said, “This wasn’t our problem because the physician never saw the patient. It was always the nurse practitioner.” So they said, “We’re going to call the nursing board and send the complaint on to them to investigate.” The medical board said, “This is not our problem. Off you go nursing board, take care of it.”

The nursing board decided to look into it, and it ended up being a seven-year legal battle. They ended up citing the nurse practitioner. She had done nothing wrong; her care was excellent. Unfortunately, this all happened. She had no support. Because she had no malpractice and no protection from board complaints, she ended up having to protect herself by learning more about the law and trying to file all of the required paperwork as she went through this very laborious process with the Board of Nursing.

She’s back in practice now. She’s recovered, but the long story short, she ended up having to mortgage her house twice to pay for all of her legal fees. It was just horrifying and something that did not need to happen.

Kevin Pho: What are the lessons that one can learn from this story? Specifically, nurse practitioners and physician assistants are a growing number and are gaining more independence throughout the country. So what are the main lessons that we can learn from this?

Surani Hayre-Kwan: The fact is that we all want to have high-quality care and protection for the care that we’re providing. Malpractice is really important for everybody, whether you are a nurse practitioner, physician, nurse, PA, nurse anesthetist, or a nurse midwife. Everyone needs to have a really solid malpractice policy to support their practice as they move into their career.

The other thing that I wanted to add is that what I’ve seen in my career is that NPs, PAs, and midwives tend to have coverage that lags behind what a physician would typically get, which is a head-scratcher to me. If you’re providing similar care, you really ought to have the same type of protection.

Kevin Pho: What are the typical malpractice insurances that nurse practitioners and physician assistants are typically offered?

Surani Hayre-Kwan: I will say that the problem with what they’re offered is that they don’t actually know what questions to ask. In my experience, I’ve had many opportunities to interact with medical groups over my career, and I can’t think of a single time that the physicians we were hiring did not ask about their tail coverage or nose coverage. They knew all of the terms.

I don’t think one time did I ever hear a nurse practitioner or a PA candidate ask those same questions, and I thought there is a gap here that needs to be addressed. We were fortunate with the organization we were with; we offered great insurance coverage for all clinicians, so that wasn’t the problem. The issue is when you start to go into situations like my colleague, who owned her own practice with her physician and did not really recognize that there was a requirement to have better coverage. Her physician had great coverage, but he’s not the one that had an issue. She did.

Kevin Pho: It sounds like that independent malpractice coverage is not independently offered to all nurse practitioners and physician assistants, especially with these smaller private groups. Am I reading that right?

Surani Hayre-Kwan: It’s more that they don’t know to ask for it. One of the key things about malpractice insurance is that you can get malpractice insurance that covers you for board complaints. There are plans that do not do that. Having a plan that specifically covers board complaints is one of the key wins in this particular case. If my colleague had kept her coverage, she would have actually had coverage for the board of nursing complaint that was filed. That whole seven-year situation likely would have been settled without any issues. We’ll never know, but that I know is true because she would have had board coverage.

Kevin Pho: Tell us the type of questions that nurse practitioners should ask specific to malpractice coverage.

Surani Hayre-Kwan: I think there are several of them. I already mentioned tail coverage and nose coverage.

Kevin Pho: So give us definitions of those for those who aren’t familiar with them.

Surani Hayre-Kwan: This is the time to take out a pen and take notes. Maybe I’ll start with occurrence and claims-made first, because that’s important to know. Occurrence coverage protects against claims related to events that happened during the policy period when you were covered, even if that claim is filed after the policy ends and maybe you’ve gone to another position. Occurrence coverage is really important for the time you’re actually doing the work with that medical group or your organization. Claims-made coverage applies only if the incident and the claim occur while the policy is active, so it is limited, and it’s important to know the difference between occurrence and claims-made. Those two things are very important to know the difference of.

Now, let’s go to tail and nose. Tail coverage extends the claims-made coverage to cover any claims filed after the policy ends for incidents that occurred while you were working for that organization. That’s what the tail means; think about it that way. Then the nose coverage, just like on a dog is the way I think about it. The nose is in front of the animal, and that is prior acts coverage, so it protects you against claims made before the start of a new claims-made policy.

Understanding those four terms and what they actually mean for coverage is really important when you are either considering a plan or starting a new job that has malpractice or does not have malpractice insurance that they make available.

Kevin Pho: Now, are there any major differences between nurse practitioner malpractice insurance versus physician malpractice insurance?

Surani Hayre-Kwan: No, not at all. The medical organizations I’ve worked for have the same cost whether you’re covering a physician, a midwife, or an NP/PA. So it’s all the same cost.

Kevin Pho: In terms of damages coverage, it’s essentially the same policy.

Surani Hayre-Kwan: Yep. Absolutely.

Kevin Pho: So why is it that organizations that allow nurse practitioners to practice independently don’t routinely offer the same malpractice coverage to them?

Surani Hayre-Kwan: It’s tricky because the nurse practitioner may have practiced in another place and they’re coming to join an organization or starting their own practice like this particular colleague of mine seeing patients in long-term care facilities. They don’t think about their coverage that they had previously and what coverage that they need in their current job. That tail and nose coverage really comes in and becomes important at that time because you are not necessarily aware of whether you had occurrence coverage for everything that happened in your previous job, or if you just had claims-made. If you had just claims-made coverage and you don’t have tail, then anything that happens following your departure from that previous job is something that you will be liable for.

In my colleague’s case, she had canceled her policy. She had occurrence coverage with board coverage, and she canceled the policy, and it was not available. So she did not think about what happens in the next one or two years or what could possibly happen, knowing that she had a really safe practice. That’s not good enough often.

Kevin Pho: And what about a distinction between physician assistants and nurse practitioners? Should there be any differences in the malpractice policies that they receive?

Surani Hayre-Kwan: No, not at all. I do see that physician assistants tend to be in the operating room more often, so you are likely to see them named in cases around surgical care. But often the surgeon is the one that bears the brunt of that particular situation, but having malpractice coverage to cover your own clinical practice is really critical because the PAs will often see the patients pre- and post-op in that kind of a situation.

The differences are basically no difference at all. The key is really making sure you have coverage for the time you’re in practice and also before and after. You might go into claims, prior acts, et cetera, and also having board coverage. So if you have any board issue, your malpractice insurance will cover that.

There will be organizations that won’t necessarily offer that. The best option is to go find your own plan to just get that board coverage. I think that’s the key. I’ve carried malpractice insurance my entire career. I never needed it because my hospital always covered me when I was an RN, and my current clinic covers me as my nurse practitioner practice has continued there, but what they don’t cover is the board coverage, which I think is an investment well made by keeping that coverage.

Kevin Pho: Off the top of your head, if you give us a ballpark figure, how often do you see nurse practitioners having to look for independent malpractice coverage because what’s offered isn’t sufficient according to our conversation today?

Surani Hayre-Kwan: I don’t know that I have a number, but I will tell you that it’s less likely that a nurse practitioner or a PA would even consider this because they don’t tend to think about liability insurance as something that is important. Particularly with board coverage, they don’t realize what could actually happen. Thus, my sharing the story of my colleague and what she went through. It did not have to happen. If she had had her malpractice insurance remain active because she had board coverage, that was the most important part of that experience for me and making sure that I shared that story with as many people as possible.

Kevin Pho: And I’m hearing more and more cases in the news as more nurse practitioners and physician assistants are practicing independently, that they are sometimes getting in trouble for bad outcomes and getting in trouble in terms of malpractice.

Surani Hayre-Kwan: The data doesn’t necessarily show that at this point. We use Candello data to look at how often things are happening, and you will see that nurse practitioner participation in liability claims is very low when you compare apples to apples with any other role. So that is something that we do watch, and I do talk about that on a regular basis.

We’re tracking that the Candello data is part of a big study that is done with Harvard. They typically collate data every 10 years, so it’s been really interesting to watch the trends, and you do see that nurse practitioners sit pretty low in all of the graphics decade after decade.

Kevin Pho: What kind of advice do you have for new nurse practitioners and physician assistants? As you said, malpractice may not be at the forefront of their minds, but as they practice independently in a variety of settings ranging from the emergency department to the operating room, any tips that you could share with them to stay out of malpractice trouble?

Surani Hayre-Kwan: So many ideas. One of the most important things is that you really have to focus on your team and their development, whoever you work with, whether it’s medical assistants or nurse aides, or other advanced practice clinicians, NPs, PAs, or whatever it is. Make sure you have a really clear process for communication within the team and also with your patients. The importance of strong communication cannot be undervalued. It is so important for the entire office or that setting to be very clear and transparent with their communications at all times.

Some of those things to think about are making sure you’re following SOAP note standards. It’s pretty basic. It doesn’t have to be a new grad, Kevin, this is everybody. Make sure your documentation is clear and concise, and not three words. It really needs to show that you have done the care for the patient. What does the continuity of care look like through the experience? And then is it defensible? I think that’s the thing I love discussing when I’m looking at documentation in anyone’s records. It’s like, is this actually a defensible note of any type?

Also, avoid premature conclusions. If you don’t actually have all the data, don’t jump to a conclusion just because you want to figure it out and move this patient out of your office and say, “OK, I’m done with that.” Take some time and look at what are the possible reasons why things are not working out for a particular patient. Whatever diagnostic error, something doesn’t feel right. The feeling you get in the back of your neck, you’re like, “No, there’s something about this isn’t right.” Pay attention to those feelings. Those are really important things to follow up on. I often will have my patients, if I have something that’s very difficult, have them tell me the story again. “How did we get here? Tell me exactly when this started.” Sometimes that alone will help us solve the problem or at least redirect us into the appropriate testing.

Finally, try to close gaps in the medical record. There is a lot of risk in gaps that are in the record that people don’t realize. A great example is not following up on abnormal results, lab, X-ray, whatever procedure. I can’t tell you how many times I have patients come in and they have a long-term problem that we’ve been trying to resolve. I’ll look at the consultant’s note and I see that the consultant wanted them back in two weeks, about four weeks, six months, whatever. I’ll ask the patient, “Hey, did you ever go back and see the specialist?” And they’re like, “Oh no, I didn’t think they wanted to see me again.” It’s like, let’s go back now because this is progressing, and they would’ve needed to know that so they could take the next step in your treatment plan.

That, again, communication to the patient about the why is very helpful in that case. I always check labs and imaging results when I’m with patients. Just take the 30 seconds, 60 seconds, and click into the tab, see if there was anything pending. Also with patients that are seeing specialists, making sure I have those consultant notes so I can actually look at them when I’m seeing the patient next. Those are gaps that are very easy to fix. They can feel very overwhelming sometimes. I’m in primary care, so it’s a lot, but it is a key way to keep yourself protected and the patient safe.

When you have challenging patients, we all have challenging patients. I think it’s really important to talk through the treatment plans with them very clearly so they understand what we’re trying to do. You want to try to avoid misunderstandings. The after-visit summaries are a great way to give the patient something to take home and look at, so they’re reminded of the conversation you had in the office. When I’m talking to patients, I’m often typing into the after-visit summary the exact same information that I’m sharing with them. As soon as I turn on the AI tool, it will do it for me, but right now I’m typing all of that into the after-visit summary.

Finally, make sure you’re prioritizing your self-care. You’re taking care of yourself so you are healthy and staying clear in your thinking when you’re taking care of patients, because consistent self-care is the best way to prevent errors and burnout in health care.

Kevin Pho: Surani Hayre-Kwan is a nurse practitioner and a member of The Doctors Company’s APC Advisory Board. Today’s KevinMD article is, “Are you protecting your career? Five essential questions about your nurse practitioner liability insurance.” Surani, let’s end with some take-home messages that you want to leave with the KevinMD audience.

Surani Hayre-Kwan: Absolutely. Malpractice isn’t about lawsuits. It’s about protecting your license, your career, and maintaining your financial stability.

Kevin Pho: Surani, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.

Surani Hayre-Kwan: Yep. Thanks so much, Kevin.