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Physicians Regulatory Insurance Program

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Title: Physicians Regulatory Insurance Program


1
Physicians RegulatoryInsurance Program
  • Presenter
  • Jay Lynch
  • President

2
Misconception in the marketplaceThe government
has moved on to more important concerns (homeland
security, war on terror, Iran, Iraq,
etc.Recoveries total over 20 billions since
1986 19 mile high stack of 1003.2 billion
in 2007 all time record for one yrROI 15
recovered for every 1 spent
3
OIG reports that nearly 1 billion in recoveries
were reported for the first quarter of 2007
4
Todays Agenda
  • Liability Exposure
  • Limiting Exposure

5
Agenda
  • Liability Exposure
  • Limiting Exposure

6
Liability Exposure
  • A contractor falsifies test results or other
    information regarding the quality or cost of
    products it sells to the Government
  • A health care provider bills Medicare for
    services that were not performed or were
    unnecessary, or
  • Performing inappropriate or unnecessary medical
    procedures in order to increase Medicare
    reimbursement.
  • Unbundling - Using multiple billing codes instead
    of one billing code for a drug panel test in
    order to increase remuneration.
  • Bundling -- Billing more for a panel of tests
    when a single test was asked for.
  • Upcoding - Inflating bills by using diagnosis
    billing codes that suggest a more expensive
    illness or treatment.
  • Billing for brand -- Billing for brand-named
    drugs when generic drugs are actually provided.

7
Liability Exposure
  • Upcoding employee work Billing at doctor rates
    for work that was actually conducted by a nurse
    or resident intern.
  • Billing for research that was never conducted
    falsifying research data that was paid for by the
    U.S. government.
  • Prescribing a medicine or recommending a type of
    treatment or diagnosis regimen in order to win
    kickbacks from hospitals, labs or pharmaceutical
    companies.
  • Billing for unlicensed or unapproved drugs.
  • Forging physician signatures when such signatures
    are required for reimbursement from Medicare or
    Medicaid.
  •  

8
Liability Exposure
  • False Claims Act
  • Application to Healthcare
  • 1 Billion Budget
  • Expanding Investigations

9
Liability Exposure
  • Complex Regulations
  • Medicare/Medicaid
  • Commercial Payor
  • Stark Law
  • HIPAA
  • EMTALA

10
The government Medicare reimbursement manual
includes 100,000 pages
11
The number of commercial Payor audits has
increased as a result of successful government
investigations
12
A New York cardiologist paid 300,000 to resolve
OIGs case against him for payment of patient
referral incentives
13
New rules governing the restricted use of patient
information create a new liability exposure for
healthcare providers
14
IOG survey results indicate that most emergency
staff members were unfamiliar with recent EMTALA
policy changes
15
Liability Exposure
  • Governments ROI
  • 231
  • Over 2.1 Billion ReturnedSince 1997
  • Save Medicare

16
Liability Exposure
  • Determining Who to Audit
  • Risk Assessment Software
  • Random Selection
  • Qui Tam (Whistle-Blower)
  • Employee
  • Patient
  • Competitor

17
Liability Exposure
  • Initiatives
  • Hospitals
  • Physicians at Teaching Hospitals
  • Lab Un-Bundling
  • 72 Hour Window
  • DRGs
  • Qui Tam

18
Liability Exposure
  • Initiatives
  • Physicians
  • Billing for Services Not Rendered
  • Upcoding
  • Quality of Care
  • Qui Tam
  • Kickbacks

19
Liability Exposure
  • Costly
  • Fines 11,000 per False Claim
  • Penalties Treble Damages

20
Liability Exposure
  • Sample Claim
  • Over a three year period Sample Physician over
    bills Medicare 20,000 in 20 separate billings
    and settles civil case for reckless conduct.
  • 20,000 Over billing
  • 60,000 Treble Damages 3 x over billing
    amount
  • 220,000 FCA Penalty 20 false claims _at_
    11,000 each
  • 300,000 Total
  • - 20,000 No coverage for the actual amount
    of over billing
  • 280,000 Total Financial Exposure

21
Agenda
  • Liability Exposure
  • Limiting Exposure

22
Limiting Exposure
  • Managing Risk
  • Compliance Program
  • Software
  • Billing
  • Compliance
  • Training/Credentials for Coders

23
Limiting Exposure
  • Transferring Risk
  • EO Insurance
  • Protects against allegations of fraud and abuse

24
Limiting Exposure
  • Defense Only Programs
  • Restrictive Wording in Policies
  • Low Limit Options
  • Limited Retrospective Coverage

25
Agenda
  • Liability Exposure
  • Limiting Exposure

26
  • Policy form addresses specific exposures not
    clearly defined
  • or specifically excluded in other policies

27
  • Indemnification
  • Expanded Regulatory Coverage
  • Higher Liability Limits
  • Prior Acts

28
  • Scaleable Coverage
  • Hospitals
  • Physicians
  • Other

29
  • Hospitals
  • Application Risk Assessment
  • Coinsurance/Retentions
  • 50 Million Limit
  • Risk Management Options

30
  • Physicians
  • Application Risk Assessment
  • 1 - 5 Million
  • Risk Management Options

31
  • Features
  • Cost Efficiencies in Defense
  • Experienced Law Firms
  • Audit team
  • Fines and Penalties
  • Risk Management/Engineering Tools
  • Due Diligence for Mergers and Acquisitions

32
Summary
  • Healthcare providers are at risk
  • EO insurance transfers risk
  • provides flexible and
  • affordable coverage

33
THE PHYSICIANS ADVOCATE, LLC866-765-1058Christ
opher Prestera, JDchris_at_phyadv.com
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