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COVERAGE FEATURES

Federal and State Government entities are not alone in the increasing scrutiny of healthcare providers and physicians. This scrutiny extends to billing, coding, privacy (HIPAA), anti-kickback and illegal referrals (Stark), Emergency Medical Treatment (EMTALA) and other violations. Medicare, Medicaid, and commercial insurance companies are launching aggressive efforts to enforce billing compliance and to recover overpayments. In many cases demands for repayment are calculated from extrapolated audits leaving the provider to defend huge amounts based on a sampling of case files.

The False Claims Act imposes liability even if a person submitting a claim does not have actual knowledge that a claim is false. Healthcare practitioners are legitimately concerned that a single unintentional violation of one of the many regulations could bankrupt their practice. Below are some of the more common regulatory issues faced by healthcare practitioners and how this program responds to them.


MEDICARE, MEDICAID, OIG & RAC POST-PAYMENT AUDIT COVERAGE

EXPOSURE & RISK: Government allegations of fraud and abuse through non-compliant billing and coding practices. Demand for repayment of alleged overpayments, including fines, penalties and interest.

COVERAGE: Indemnifies the practitioner up to $1,000,000 and pays all fines, penalties and interest, as well as the cost of legal defense including attorney’s fees, expert witnesses and costs for reproduction of case files, documentation and shadow audits.


COMMERCIAL PAYOR AUDIT COVERAGE

EXPOSURE & RISK: Commercial payor allegations of fraud and abuse including demands for repayment of alleged overpayments, and in some cases, penalties and interest.

COVERAGE: Coverage expands beyond governmental audits to include all commercial insurance carriers. Indemnifies the practitioner up to $1,000,000 and pays all fines, penalties and interest, as well as the cost of legal defense including attorney’s fees, expert witnesses and costs for reproduction of case files, documentation and shadow audits.


HIPAA VIOLATIONS

EXPOSURE & RISK: Rules and regulations governing the restricted use of patient information.

COVERAGE: Indemnifies the practitioner up to $1,000,000 and pays all fines and penalties levied by Federal or State enforcement agencies as a result of allegations of HIPAA violations Also includes all costs of legal representation and defense.


STARK & ANTI-KICKBACK VIOLATIONS

EXPOSURE & RISK: Non-compliant referral agreements and anti-kickback violations.

COVERAGE: Indemnifies the practitioner up to $1,000,000 and pays all fines and penalties levied by Federal or State enforcement agencies as a result of allegations of Stark or Anti-Kickback violations. Also includes all costs of legal representation and defense.


EMTALA VIOLATIONS

EXPOSURE & RISK: Healthcare practitioners who are involved in emergency medicine have exposure and risk under the Emergency Medical Treatment Active Labor Act (EMTALA). Fines and penalties for violations can run into hundreds of thousands of dollars.

COVERAGE: Provides defense and indemnity up to $1,000,000 covering all legal fees and representation costs, fines and penalties if allegations of non-compliance are made against practitioners who provide emergency medical care.


AUDIT TARGETS: INDIVIDUAL HEALTHCARE PRACTITIONERS AND PHYSICIAN GROUPS


PROGRAM FEATURES

• Up to 6 years retroactive coverage
• Payment of all fines and penalties up to $1,000,000 (up to $5,000,000 for groups)
• Coverage for all defense costs including attorney fees, consultants, expert witnesses, reproduction costs and shadow audits, after $2,500 deductible
• Simple underwriting process (completion of a 3 page application)
• Average premium is $1,400-$1,600 annually per physician, discounts for groups
• Fast, no obligation approvals and quotes
• Underwritten by Lloyds of London

The maximum reimbursed for each claim, and in the annual aggregate against an Insured Person during the Policy Period, is $1,000,000. The maximum reimbursed for each claim and in the annual aggregate against more than one Insured Person in a group (including the Corporation) during the Policy Period shall be based on the number of Insured Persons in the group at the time a claim is made, as shown in the table above.

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