Title: Physicians Regulatory Insurance Program
1Physicians RegulatoryInsurance Program
- Presenter
- Jay Lynch
- President
2Misconception 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
3OIG reports that nearly 1 billion in recoveries
were reported for the first quarter of 2007
4Todays Agenda
- Liability Exposure
- Limiting Exposure
-
5Agenda
- Liability Exposure
- Limiting Exposure
-
6Liability 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.
7Liability 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. -
8Liability Exposure
- False Claims Act
- Application to Healthcare
- 1 Billion Budget
- Expanding Investigations
9Liability Exposure
- Complex Regulations
- Medicare/Medicaid
- Commercial Payor
- Stark Law
- HIPAA
- EMTALA
10The government Medicare reimbursement manual
includes 100,000 pages
11The number of commercial Payor audits has
increased as a result of successful government
investigations
12A New York cardiologist paid 300,000 to resolve
OIGs case against him for payment of patient
referral incentives
13New rules governing the restricted use of patient
information create a new liability exposure for
healthcare providers
14IOG survey results indicate that most emergency
staff members were unfamiliar with recent EMTALA
policy changes
15Liability Exposure
- Governments ROI
- 231
- Over 2.1 Billion ReturnedSince 1997
- Save Medicare
16Liability Exposure
- Determining Who to Audit
- Risk Assessment Software
- Random Selection
- Qui Tam (Whistle-Blower)
- Employee
- Patient
- Competitor
17Liability Exposure
- Initiatives
- Hospitals
- Physicians at Teaching Hospitals
- Lab Un-Bundling
- 72 Hour Window
- DRGs
- Qui Tam
18Liability Exposure
- Initiatives
- Physicians
- Billing for Services Not Rendered
- Upcoding
- Quality of Care
- Qui Tam
- Kickbacks
19Liability Exposure
- Costly
- Fines 11,000 per False Claim
- Penalties Treble Damages
20Liability 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
21Agenda
- Liability Exposure
- Limiting Exposure
-
22Limiting Exposure
- Managing Risk
- Compliance Program
- Software
- Billing
- Compliance
- Training/Credentials for Coders
23Limiting Exposure
- Transferring Risk
- EO Insurance
- Protects against allegations of fraud and abuse
24Limiting Exposure
- Defense Only Programs
- Restrictive Wording in Policies
- Low Limit Options
- Limited Retrospective Coverage
25Agenda
- 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
32Summary
- Healthcare providers are at risk
- EO insurance transfers risk
- provides flexible and
- affordable coverage
33THE PHYSICIANS ADVOCATE, LLC866-765-1058Christ
opher Prestera, JDchris_at_phyadv.com