Because of the escalating pace of legislative and administrative health care reform activities, you are likely to be in technical violation of at least one billing regulation at any given time, no matter how scrupulous and thorough your billing procedures. In addition, commercial insurance programs, or "private payors," have their own rules for proper billing that must be followed for payment to ensue. Thus, it is becoming more important to financially protect yourself and your practice in the event you fall under scrutiny for your billing practices.
Hot on the heels of the government's Medicare/Medicaid fraud and abuse iniative, another potential regulatory nightmare for ophthalmologists looms. The Health Insurance Portability and Accountability Act (HIPAA), one of the federal laws invoked in anti-fraud cases contains new patient information privacy regulations enforceable beginning April 2003. This complex set of rules sets stringent standards for maintaining the privacy of individually identifiable health information. However, unlike the witch-hunt tactics of the anti-fraud forces, the U.S. Health & Human Services Department is encouraging cooperation and assistance to help providers achieve compliance. Punitive enforcement, at this point, is not a priority. However, civil fines, lawsuits, criminal fines, and imprisonment are tools the government can emply if it chooses to aggressively ferret out non-compliers.
In response to thes crises, OMIC has developed a Fraud & Abuse/HIPAA Privacy Insurance policy available to members of the American Academy of Ophthalmology. In addition, OMIC's highly acclaimed risk management programs and services are available to help policyholders comply with the government's rules for proper Medicare and Medicaid billing and to meet HIPAA Privacy Compliance standards.
OMIC Fraud & Abuse Policy Q & A
All information is for policies incepting on or after 1/1/2002.
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 claims are covered by OMIC's Fraud & Abuse/HIPAA Privacy insurance policies?
OMIC's policies cover civil investigations or proceedings instituted by a government agency, a qui tam plaintiff (whistleblower), or a commercial payer alleging the presentation of erroneous billings by the insured to the government health benefit payor or commercial payer AND government proceedings based on violations of the HIPAA (Health Insurance Portability and Accountability Act) Privacy rules.
What losses are covered?
OMIC offers two types of Fraud & Abuse/HIPAA Privacy Insurance: Legal Expense Fraud & Abuse/HIPAA Privacy Insurance and Comprehensive Fraud & Abuse/HIPAA Privacy Insurance.
OMIC's Fraud & Abuse/HIPAA Privacy policy pays for attorney's fees and associated expenses rendered in the defense of claims.
OMIC's Comprehensive Fraud & Abuse/HIPAA Privacy policy covers reimbursement for legal fees and expenses plus certain audit expenses and fines and penalties assessed due to billing errors and HIPAA privacy regulatory proceedings.
Neither policies pay for any damages or return of any overbilling or profits.
Who may obtain coverage?
Any individual who participates in billing Medicare/Medicaid could be involved in a billings investigation or proceedings. Under the Fraud & Abuse/HIPAA Privacy insurance policy, 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 OMIC Fraud & Abuse/HIPAA Privacy insureds, may obtain coverage.
Under the Comprehensive Fraud & Abuse/HIPAA Privacy policy, individual physicians or groups of physicians and their employed optometrists may obtain coverage.
What are the policy limits?
OMIC offers different limits depending on the type of Fraud & Abuse/HIPAA Privacy insurance product. OMIC automatically provides Fraud & Abuse/HIPAA Privacy insurance at limits of $25,000
without charge to OMIC medical professional liability policyholders. Professional liablity policyholders can increase their limits to $50,000 or $100,000.
Members of the American Academy of Ophthalmology who are not covered by OMIC for professional liability may also purchase this coverage at limits of $25,000, $50,000 or $100,000.
OMIC and Non-OMIC professional liability policyholders who are members of the Academy of OPhthalmology may purchase Comprehensive Fraud & Abuse/HIPAA Privacy Insurance. Policy limits for OMIC's Comprehensive Fraud & Abuse/HIPAA Privacy insurance are $250,000, $500,000, or $1,000,000.
Is there any exclusion of coverage if the proceeding or investigation pertains to billing records or events prior to my 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, underwriting considerations may require certain Comprehensive 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 retirees?
This policy is also offered at discounted rates to retirees who are current active or inactive members of the American Academy of Ophthalmology. It covers governmental proceedings based upon events that occurred before the insured's retirement. Basic policy limits of $25,000 are available to all new applicants and renewing policyholders. Current OMIC Fraud and Abuse policyholders with Higher Limits of $50,000 and $100,000 may carry over these limits to their Retiree Policy.
What are the costs of OMIC's Fraud & Abuse/HIPAA Privacy insurance policies?
Contact an OMIC representative at (800) 610-6642 for information about OMIC's competitive pricing.
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. Various coverages may not be available in all states.
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