Policyholder Services

OMIC Coverage Benefit for Billing Errors (“Fraud and Abuse”) Allegations

What types of billing errors proceedings are covered by OMIC’s Broad Regulatory Protection coverage?

This benefit covers civil investigations or proceedings instituted against the Insured by a qui tam plaintiff (a whistleblower) under the federal False Claims Act, by a government entity, or by a commercial payer alleging presentation of erroneous billings by the Insured to a government health benefit payer or commercial payer. It also covers such actions if they stem from the Insured’s voluntary self disclosure to a government entity. This occurs when an Insured disclosed information to the government without their prior request that may serve as grounds for a billing errors proceeding.

What billing errors losses are covered?

BRP covers reimbursement for legal expenses for billing errors proceedings. This includes attorney’s fees and associated expenses, plus related consultant fees if pre-approved by OMIC. The benefit also covers audit expenses incurred in the course of a shadow audit. A shadow audit is a professional examination of the billing records and related documents subject to an ongoing billing errors proceeding, performed to give the Insured a private expert opinion. BRP also covers administrative fines or penalties (when allowed by law) assessed due to billing errors proceedings. The policy does not pay for any damages or return of any overbilling or profits. It also does not cover the costs of adopting and implementing a corporate integrity agreement, compliance program, or similar policy negotiated as part of a settlement with or by order of a government entity.

How are billing errors investigations typically initiated?

Investigations typically begin when a Medicare, Medicaid, or commercial payer detects an anomaly in billing patterns; when competitors, patients, or employees lodge complaints; and from random sampling.

What do billing errors 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

Learn about all of the Additional Benefits Included in OMIC’s Standard Professional Liability Policy.


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