MEDEFENSE™ Plus Protection from Regulatory Billing Investigations
A vital part of the
proposed
healthcare
overhaul targets
an estimated $60
billion a year in
Medical fraud.
With a
microscope on
billings, is your
healthcare
provider
protected?
Healthcare providers, including: hospitals, physician practices, nursing
homes, home health agencies, durable medical equipment suppliers and
any other provider or supplier that bills Medicare Parts A and B are now
faced with the reality that the Recovery Audit Contractor (RAC) audits
have spread nationwide!
Defined by the Centers for Medicare and Medicaid Services
(CMS) as an aggressive program to “find and prevent waste,
fraud and abuse in Medicare,” federally hired contractors, paid
on a contingency basis (i.e. retaining between 9%-12% of
payments recovered), have recouped more than $993 million as
of 2008 in improper payments that did not meet Medicare’s
coding or medical necessity policies.
In addition to physically reviewing medical records, RACs also use electronic
automated reviews searching for billing patterns that appear higher than the
majority of providers in the community. Improper payments on claims can
occur for the following reasons:
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MEDEFENSE™ Plus
offers coverage for
attorney and audit
costs incurred in
response to actions
or proceedings
resulting from RAC
audit finding, as
well as payment for
potential fines and
penalties. In
addition,
MEDEFENSE™ Plus
provides defense
cost and civil fines
and penalties
coverage for HIPAA,
STARK and EMTALA
proceedings.
Payments are made for services that do not meet Medicare’s medical
necessity criteria.
Payments are made for services that are incorrectly coded.
Providers fail to submit documentation when requested, or fail to
submit enough documentation to support the claim.
Other reasons, such as basing claim payments on outdated fee
schedules, or the provider is paid twice because duplicate claims
were submitted.
RAC audits are immediate, overwhelming and
burdensome
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Government inquiries allow only 30 days for response.
Government take-backs can occur in 60 days or less.
Compliance and documentation are critical but not always sufficient.
Severe penalties can be incurred for those who are unprepared.
MEDEFENSE™ Plus Highlights
Limits:
Up to $5,000,000 each claim/$5,000,000 aggregate
Features: MEDEFENSE™ PLUS - Defense costs and civil fines and
penalties coverage for Billing Errors, HIPAA, EMTALA and
Stark proceedings
Full Prior Acts available
Broad definition of Billing Errors Proceedings to include both
governmental and commercial payor audits and
investigations, qui tam plaintiffs, or voluntary self-disclosure
Up to $100,000 legal expense coverage for disciplinary
proceedings by a state Medical Board can be added via
endorsement.
ProAssurance Agency
New Combined Medefense™ Plus / e-MD™ Policy
Physicians and other healthcare entities are increasingly exposed to privacy related
claims and things like a lost laptop, rogue employee, hacking and virus attacks can
result in an embarrassing and costly loss. e-MD™ from NAS Insurance is insurance
protection designed for the unique Network Security & Privacy related exposures faced by
dentists, physicians, medical groups and other medical professionals. This can now be
added to a MEDEFENSE™ Plus policy for a reduced rate, or purchased separately.
MEDEFENSE™ Plus / e-MD™ Enhanced COVERAGE COMPONENTS
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Network Security & Privacy Insurance – Will defend and indemnify
insured for any claims arising out of a breach of privacy, virus attacks, denial
of service, first-party HIPAA violation, and Red Flag Regulations. Includes
coverage for both electronic and physical information.
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Patient Notification & Credit Monitoring Costs Insurance – If your
organization suffers an information breach, most states require that you
notify all the affected people that their information has been compromised.
e-MD™ includes coverage for all necessary legal, PR, electronic forensics,
advertising and postage expenses incurred by the insured to notify third
persons of a breach of information. Will also pay for 1 year of credit
monitoring for the affected people, so they can monitor their accounts and
be sure there aren’t any new fraudulent accounts and/or transactions.
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Data Recovery Costs Insurance – Will pay the insured for all reasonable
and necessary sums required to recover and/or replace data that is
compromised, damaged, lost, erased or corrupted. This also includes
software costs.
The latest round of stimulus funds set aside significant incentives for the digitization of
our country’s medical records, and facilities are moving quickly to take advantage of this
situation. Electronic medical records are much easier to steal/lose in bulk than paper
patient files. In the last year, more than 10,000,000 identities have been exposed in
healthcare related breaches; and this happened in a year when the vast majority of
medical facilities have not converted to digital records. The average cost to an
organization is almost $200 per identity lost. New regulations like the Hi-Tech Act and
Red Flag Rules are complicating the already unpredictable regulatory environment, and
will lead to an increase in Fines and Penalties. The time to discuss Network Security
& Privacy Insurance with your clients is now!