Policyholder Services

What does Regulatory Protection insurance cover?

Regulatory policies usually provide coverage 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.

Examples include “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

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