Broad Regulatory Protection Policy
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OMIC was one of the first malpractice carriers in the United States to cover its policyholders for claims related to fraud and abuse “billing errors” allegations and other regulatory exposures. In early 1999, OMIC first offered this regulatory reimbursement coverage free of charge for insureds as an added benefit of maintaining malpractice insurance through OMIC. OMIC contracted with Lloyds of London to provide underwriting and claims services. The policy was broadened several times in subsequent years to include coverage for HIPAA privacy violations, civil proceedings, qui tam (whistleblower) allegations, and private payor billing investigations.
Coverage was further expanded in 2005 to include legal expense reimbursement for Emergency Medical Treatment and Active Labor Act (EMTALA) claims, certain disciplinary proceedings, and alleged violations of DEA and STARK Act regulations. In 2010, coverage was again expanded and included as a $35,000 sublimit within OMIC’s professional liability policy. Reimbursement coverage at a $10,000 sublimit for patient notification costs and Red Flag Rule violations was also added.
Underwriting and claims services continue to be administered by Lloyds of London due to their expertise in the field of regulatory coverage. For more information regarding the terms and conditions for this coverage, OMIC professional liability policyholders may refer to their policy booklet under Section VII. Additional Benefits.
Policyholders interested in purchasing higher limits or expanded coverage for these exposures (or non-OMIC insureds interested in purchasing basic or expanded coverage) can contact Lloyds of London through our program representative, Dana Pollard, at NAS Insurance Services (877) 808-6277 or dpollard@nasinsurance.com.
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OMIC Broad Regulatory Protection Policy Q & A
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All information is for OMIC policies incepting on or after 1/1/2010.
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What claims are covered by OMIC's Broad Regulatory Protection coverage?
This sublimit in OMIC's professional liability policy covers "fraud and abuse" actions related to civil investigations or proceedings instituted by a government agency, a qui tam plaintiff (whistleblower), or a commercial payor alleging the presentation of erroneous billings by the insured to the government health benefit payor or commercial payor. It also covers government proceedings based on alleged violations of the HIPAA (Health Insurance Portability and Accountability Act) Privacy rules. Coverage is also provided for claims related to alleged violations of EMTALA, DEA and STARK regulations and certain disciplinary proceedings not related to a professional services incident.
How are billing errors investigations typically initiated?
Investigations typically begin when a Medicare, Medicaid or commercial payor detects an anomaly in billing patterns; when competitors, patients or employees lodge complaints; and from random sampling.
What do "fraud & abuse" investigations typically pertain to?
Billing issues that may lead to a Medicare or Medicaid investigation may include
such things as: |
Billing for services not performed
Upcoding of services
Inadequate documentation to support the services provided
Use of incorrect CPT codes
Unbundling or fragmentation of services
Providing medically unnecessary services
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What losses are covered
OMIC's Broad Regulatory Protection Policy covers reimbursement for legal
fees and expenses, certain audit expenses, and fines and penalties (when allowed
by law) assessed due to billing errors and HIPAA privacy proceedings. The policy
does not pay for any damages or return of any overbilling or profits.
Who may obtain coverage?
Individual American Academy of Ophthalmology (AAO) members and their employed
optometrists may obtain coverage. Also, business entities with two or more physician
members, all of whose physician members are individual Broad Regulatory Protection
Policy insureds, may obtain coverage
What are the policy limits?
OMIC and Lloyds of London offer several liability limits for the Broad Regulatory Protection coverage. OMIC professional liability policyholders are provided with a $35,000 sublimit under the standard professional liability policy at no additional charge. This coverage is automatically provided under the OMIC malpractice policy and no action is required by active OMIC professional liability policyholders to receive this coverage.
OMIC's professional liability policyholders may also purchase additional coverage up to $1 million above the standard coverage that is automatically provided by OMIC. Insureds interested in purchasing additional coverage can access BRPP upgrade forms may be obtained from NAS Insurance Services at the number listed below or downloaded from the Members Only section of this web site. (contact your underwriter for password information for the members section)
Members of the American Academy of Ophthalmology who are not covered by OMIC for professional liability may purchase this coverage directly from Lloyds of London at limits up to $1 million.
Is there any exclusion of coverage if the proceeding or investigation pertains to billing records or events prior to the policy effective date?
So long as the investigation and claim are first instituted during your policy period, there is no coverage restriction as to when the alleged billing error or event occurred. However, for part or all of this coverage, underwriting considerations may require certain policyholders to carry a retroactive date, whereby coverage is restricted to claims based on alleged billing errors or events occurring after the retroactive date.
Is this policy available to optometrists who are insured under an OMIC policy?
Yes. This policy is available to OMIC-insured optometrists; however, they must purchase this coverage. OMIC provides BRPP coverage for OMIC physician and entity policyholders only. Contact the plan administrator for rates and information.
Is this policy available to retirees?
Please note that OMIC provides a free lifetime professional liability retirement endorsement ("tail" policy) to its insureds who fully retire and have been insured for professional liability for at least five continuous years prior to retirement. For expanded coverage purchased through Lloyds of London, an extended reporting period endorsement for an additional 12 months of reporting past the policy expiration date can be purchased for an additional premium.
What are the costs of OMIC's Broad Regulatory Protection Policy?
Contact the program representative, Dana Pollard, at NAS Insurance Services (877) 808-6277 (or dpollard@nasinsurance.com) for information about the competitive pricing for the limits and coverage that are appropriate for your practice.
These questions and answers are for informational purposes only. They are not intended to be a modification of the terms and conditions of the OMIC/Academy-sponsored insurance policies. Some coverages may not be available in all states.
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