Risk Management

RAC Audit. Cyber/eMD Breach. Who Ya Gonna Call?

The Obama Administration continues to focus energy on fighting fraud & abuse within healthcare under the “Campaign to Cut Waste” established nearly three years ago. By some estimates, the government has recovered $7 in fraudulent payments for every $1 spent on the program so far.  The Department of Justice recovered over $2.8 billion in healthcare fraud in 2011 and began prosecutions for more than $1 billion in newly identified fraudulent claims.

The focus on healthcare fraud is no surprise given the government estimate of $90 billion in fraudulent payments of CMS’s funds each year. Until recently, however, most claims activity has targeted large hospital networks and facilities rather than smaller private ophthalmic practices. But this is changing.

To date, OMIC has recorded approximately 300 claims against our insureds for Medicare/Medicaid and Commercial Payor billing errors (“fraud and abuse”) allegations.

OMIC was one of the first malpractice carriers in the United States to include regulatory coverage within its malpractice policy. Called BRP (Broad Regulatory Protection) and eMD (Cyber Liability and Patient Notification Protection), policyholders are provided with a benefit sublimit that covers billing errors allegations as well as many other regulatory and electronic data liabilities.

Billing allegations covered:

• 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