Broad Regulatory Protection Policy

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. This benefit provides reimbursement for legal expenses, fines, and penalties (where allowed by law) to defend against allegations of fraud, abuse, and billing errors by Medicare, Medicaid, and commercial health plans, including RAC audits. It also responds to alleged violations of HIPAA Privacy laws and EMTALA, DEA, Stark Act, Red Flag, HITECH, and Gramm-Leach-Bliley regulations.

Effective January 1, 2011, OMIC increased the benefit limit for BRPP exposures to $50,000 per policy period. OMIC professional liability policyholders are automatically provided with this coverage so no action on your part is required. For more information regarding the terms and conditions for this benefit, OMIC professional liability policyholders may refer to their policy booklet under Section VII. Additional Benefits. A separate policy insert describing the cyber liability coverage and higher BRPP coverage limit will be included in 2011 renewal packets or sent to insureds under separate cover. Please call your Underwriter if you require another copy.

Underwriting and claims services are administered by Lloyds of London due to their expertise in the field of regulatory coverage.

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 Agency (877) 808-6277 or dpollard@nasinsurance.com.

OMIC Broad Regulatory Protection Policy Q & A

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, STARK, Red Flag, HITECH, and Gramm-Leach-Bliley 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

What is included within the "cyber liability" coverage provided under BRPP?

Privacy Violations - Reimburses for fines and penalties associated with breach of federal state or local statutes related to personal medical or financial information including HIPPA, Gramm-Leach-Billey Act, HITECH, FTC and Fair Credit Reporting Act. Also responds to general allegations by patients of violations or release of their private information.

Network Security - Reimburses damages related to inadvertent transmission of harmful viruses, unauthorized access to sensitive information stored on computer systems, prevention of authorized access to computer systems, and failure to prevent identity theft or credit/debit card fraud. Data Interference – Reimburses for damage to sensitive data you maintain through intrusion of computer systems and electronic communication devices without your knowledge, whether intentional, malicious, reckless or negligent.

Patient Notification - Reimburses for costs related to patient notification of privacy breaches, including all reasonable legal, public relations, advertising, IT forensic, call center, credit monitoring and postage expenses incurred.

Data Recovery - Reimburses all reasonable and necessary expenses required to recover and/or replace data that is compromised, damaged, lost, erased or corrupted.

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, EMTALA, DEA , STARK, Red Flag, HITECH, and Gramm-Leach-Bliley 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 $50,000 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?

Policyholders interested in purchasing higher limits or expanded coverage for these exposures (or non-OMIC insureds interested in purchasing basic or expanded coverage) should contact Lloyds of London through our program representative, Dana Pollard, at NAS Insurance Agency (877) 808-6277 or dpollard@nasinsurance.com for rates and additional information.

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.