Physicians Regulatory Insurance Program

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Physicians RegulatoryInsurance Program

• Presenter
• Jay Lynch
• President

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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
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OIG reports that nearly 1 billion in recoveries
were reported for the first quarter of 2007
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Todays Agenda

• Liability Exposure
• Limiting Exposure

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Agenda

• Liability Exposure
• Limiting Exposure

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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.

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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.
•  

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Liability Exposure

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

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Liability Exposure

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

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

• Governments ROI
• 231
• Over 2.1 Billion ReturnedSince 1997
• Save Medicare

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Liability Exposure

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

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Liability Exposure

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

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Liability Exposure

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

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Liability Exposure

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

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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

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Agenda

• Liability Exposure
• Limiting Exposure

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Limiting Exposure

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

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Limiting Exposure

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

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Limiting Exposure

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

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Agenda

• Liability Exposure
• Limiting Exposure

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

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

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• Scaleable Coverage
• Hospitals
• Physicians
• Other

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

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

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

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Summary

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

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