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Transcript of Physicians Regulatory Insurance Program Presenter: Jay Lynch President Presenter: Jay Lynch...
Physicians RegulatoryInsurance Program
Physicians RegulatoryInsurance Program
Presenter:Jay LynchPresident
Presenter:Jay LynchPresident
Misconception in the marketplace
The 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 $100
$3.2 billion in 2007 = all time record for one yr
ROI = $15 recovered for every $1 spent
Misconception in the marketplace
The 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 $100
$3.2 billion in 2007 = all time record for one yr
ROI = $15 recovered for every $1 spent
OIG reports that nearly $1 billion in recoveries were reported for the first quarter of 2007
OIG reports that nearly $1 billion in recoveries were reported for the first quarter of 2007
Today’s AgendaToday’s Agenda
Liability Exposure Limiting Exposure
Liability Exposure Limiting Exposure
AgendaAgenda
Liability Exposure Limiting Exposure
Liability Exposure Limiting Exposure
Liability ExposureLiability 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.
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.
Liability ExposureLiability 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.
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.
Liability ExposureLiability Exposure
False Claims Act Application to Healthcare $1 Billion Budget Expanding Investigations
False Claims Act Application to Healthcare $1 Billion Budget Expanding Investigations
Liability ExposureLiability Exposure
Complex Regulations Medicare/Medicaid Commercial Payor Stark Law HIPAA EMTALA
Complex Regulations Medicare/Medicaid Commercial Payor Stark Law HIPAA EMTALA
The government Medicare reimbursement manual includes 100,000 +100,000 + pages
The government Medicare reimbursement manual includes 100,000 +100,000 + pages
The number of commercial Payor audits has increasedincreased as a result of successful government investigations
The number of commercial Payor audits has increasedincreased as a result of successful government investigations
A New York cardiologist paid $300,000$300,000 to resolve OIG’s case against him for payment of patient referral incentives
A New York cardiologist paid $300,000$300,000 to resolve OIG’s case against him for payment of patient referral incentives
New rules governing the restricted use of patient information create a new liability new liability exposureexposure for healthcare providers
New rules governing the restricted use of patient information create a new liability new liability exposureexposure for healthcare providers
IOG survey results indicate that most emergency staff members were unfamiliar with unfamiliar with recent EMTALA recent EMTALA policy changespolicy changes
IOG survey results indicate that most emergency staff members were unfamiliar with unfamiliar with recent EMTALA recent EMTALA policy changespolicy changes
Liability ExposureLiability Exposure
Government’s ROI 23:1 Over $2.1 Billion Returned
Since 1997 Save Medicare
Government’s ROI 23:1 Over $2.1 Billion Returned
Since 1997 Save Medicare
Liability ExposureLiability Exposure
Determining Who to Audit: Risk Assessment Software Random Selection Qui Tam (Whistle-Blower)– Employee– Patient– Competitor
Determining Who to Audit: Risk Assessment Software Random Selection Qui Tam (Whistle-Blower)– Employee– Patient– Competitor
Liability ExposureLiability Exposure
Initiatives Hospitals– Physicians at Teaching Hospitals– Lab Un-Bundling– 72 Hour Window– DRG’s– Qui Tam
Initiatives Hospitals– Physicians at Teaching Hospitals– Lab Un-Bundling– 72 Hour Window– DRG’s– Qui Tam
Liability ExposureLiability Exposure
Initiatives Physicians– Billing for Services Not Rendered– Upcoding– Quality of Care– Qui Tam– Kickbacks
Initiatives Physicians– Billing for Services Not Rendered– Upcoding– Quality of Care– Qui Tam– Kickbacks
Liability ExposureLiability Exposure
Costly Fines: $11,000 per False Claim Penalties: Treble Damages
Costly Fines: $11,000 per False Claim Penalties: Treble Damages
Liability ExposureLiability ExposureSample 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 @ $11,000 each$300,000 Total- $20,000 No coverage for the actual amount of over billing$280,000 Total Financial 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 @ $11,000 each$300,000 Total- $20,000 No coverage for the actual amount of over billing$280,000 Total Financial Exposure
AgendaAgenda
Liability ExposureLimiting Exposure
Liability ExposureLimiting Exposure
Limiting ExposureLimiting Exposure
Managing Risk Compliance Program Software– Billing– Compliance
Training/Credentials for Coders
Managing Risk Compliance Program Software– Billing– Compliance
Training/Credentials for Coders
Limiting ExposureLimiting Exposure
Transferring Risk E&O Insurance
Protects against allegations of fraud and abuse
Transferring Risk E&O Insurance
Protects against allegations of fraud and abuse
Limiting ExposureLimiting Exposure
Defense Only Programs Restrictive Wording in Policies Low Limit Options Limited Retrospective Coverage
Defense Only Programs Restrictive Wording in Policies Low Limit Options Limited Retrospective Coverage
AgendaAgenda
Liability Exposure Limiting Exposure
Liability Exposure Limiting Exposure
Policy form addresses specific exposures not clearly defined or specifically excluded in other policies
Policy form addresses specific exposures not clearly defined or specifically excluded in other policies
Indemnification Expanded Regulatory Coverage Higher Liability Limits Prior Acts
Indemnification Expanded Regulatory Coverage Higher Liability Limits Prior Acts
Scaleable Coverage Hospitals Physicians Other
Scaleable Coverage Hospitals Physicians Other
Hospitals Application & Risk Assessment Coinsurance/Retentions $50 Million Limit Risk Management Options
Hospitals Application & Risk Assessment Coinsurance/Retentions $50 Million Limit Risk Management Options
Physicians Application & Risk Assessment $1 - 5 Million Risk Management Options
Physicians Application & Risk Assessment $1 - 5 Million Risk Management Options
Features Cost Efficiencies in Defense– Experienced Law Firms– Audit team
Fines and Penalties Risk Management/Engineering Tools Due Diligence for Mergers and
Acquisitions
Features Cost Efficiencies in Defense– Experienced Law Firms– Audit team
Fines and Penalties Risk Management/Engineering Tools Due Diligence for Mergers and
Acquisitions
SummarySummary
Healthcare providers are at risk E&O insurance transfers risk
provides provides flexible and
affordable coverage
Healthcare providers are at risk E&O insurance transfers risk
provides provides flexible and
affordable coverage
THE PHYSICIANS ADVOCATE, LLC
866-765-1058Christopher Prestera, JD
THE PHYSICIANS ADVOCATE, LLC
866-765-1058Christopher Prestera, JD