RAC Audit

Physician Regulatory / RAC Audit Insurance

The FFActs Insurance Program has been initiated to insure and provide expert legal and negotiation services to healthcare providers who have been penalized or fined in association with the unintentional over billing of Medicare, Medicaid, and Commercial Payers.

 Over 40,000 Healthcare Practitioners Covered Nationwide

View or Download Brochure(s): 

RAC Audit Insurance Flyer      RAC Audit Insurance Tri-Fold Brochure 

Audit Application

Why is this coverage needed?

While the False Claims Act imposes liability even if the person submitting the claim does not have actual knowledge that the claim is false. A person who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information also can be found liable under the Act.

• Anyone with a Medicare provider number is subject to an audit
• Since 1985 – $30 billion in recoveries by the Feds
• In 2008 thru September alone, $6 billion recovered
• ROI for Federal Government – $15 per $1 spent
• Commercial audits, EMTALA, STARK, HIPAA compliance
• Providers are liable for the mistakes of billing companies

Who is auditing?

• Fiscal Intermediaries
• Office of Inspector General (OIG)
• US Attorneys / State Prosecutors
• Whistleblowers
• Recovery Audit Contractors (RAC Audits)
• Sophisticated Audit Software

Medicare / Medicaid Audits and the impact on the healthcare industry

• In 2006, three trial contracts issued for RACs
• Recovered over $1 billion in three states
• Additional RACs to be contracted
• For every 100 bills reviewed, 70 mistakes found
• Focused initiatives on procedures most frequently billed in error

Sample regulatory cases made against

• A single cardiologist inadvertently overbilled Medicare for elderly patients for six years settled for $2.6 million
• A cardiac rehab center charged with overbilling Medicare for six years settled for $1.9 million
• An ophthalmologist accused of filing false claims to Medicare for work deemed medically unnecessary settled for $1 million
• Two physicians accused of taking noncompliant hospital referral fees settled over $1 million
• A hospital system self – reported potential errors settled for $60 million!

 Coverage provides

•  All costs associated with defending a healthcare provider (legal, consultant, reproduction costs, shadow audit work)
• Audit fines and penalties
• Implementation of Corporate Integrity Agreements is not covered

 

$1,000,000 Limits of Liability per provider/claim

Physicians Billing Errors & Omissions / Regulatory Insurance Program

Underwritten by Lloyds
of London ®

Federal and State Government entities are not alone in the increasing scrutiny of healthcare providers and physicians. This scrutiny extends to billing, coding, privacy (HIPAA), Anti-kickback and illegal referrals (Stark), Emergency Medical Treatment (EMTALA) and other violations. Medicare, Medicaid, and commercial insurance companies are launching aggressive efforts to enforce billing compliance and to recover overpayments. In many cases demands for repayment are calculated from extrapolated audits leaving the provider to defend huge amounts based on a sampling of case files.  The False Claims Act imposes liability even if a person submitting a claim does not have actual knowledge that a claim is false. Healthcare practitioners are legitimately concerned that a single unintentional violation of one of the many regulations could bankrupt their practice.

 

Common regulatory issues faced by healthcare practitioners and how this program responds to them:

 

MEDICARE, MEDICAID, OIG & RAC POST-PAYMENT AUDIT
COVERAGE

EXPOSURE & RISK: Government allegations of fraud and abuse through non-compliant billing and coding practices. Demand for repayment of alleged overpayments, including fines, penalties and interest.

COVERAGE: Indemnifies the practitioner up to $1,000,000 and pays all fines, penalties and interest, as well as the cost of legal defense including attorney’s fees,expert witnesses and costs for reproduction of case files, documentation and shadow audits.

COMMERCIAL PAYOR AUDIT COVERAGE

EXPOSURE & RISK: Commercial payor allegations of fraud and abuse including demands for repayment of alleged overpayments, and in some cases, penalties and interest.

COVERAGE: Coverage expands beyond governmental audits to include all commercial insurance carriers.  Indemnifies the practitioner up to $1,000,000 and pays all fines, penalties and interest, as well as the cost of legal defense including attorney’s fees, expert witnesses and costs for reproduction of case files, documentation and shadow audits.

HIPAA VIOLATIONS

EXPOSURE & RISK: Rules and regulations governing the restricted use of patient information.

COVERAGE: Indemnifies the practitioner up to $1,000,000 and pays all fines and penalties levied by Federal or State enforcement agencies as a result of allegations of HIPAA violations Also includes all costs of legal representation and defense.

STARK & ANTI-KICKBACK VIOLATIONS

EXPOSURE & RISK: Non-compliant referral agreements and anti-kickback violations.

COVERAGE: Indemnifies the practitioner up to $1,000,000 and pays all fines and penalties levied by Federalor State enforcement agencies as a result of allegations of Stark or Anti-Kickback violations. Also includes all costs of legal representation and defense.

EMTALA VIOLATIONS

EXPOSURE & RISK: Healthcare practitioners who are involved in emergency medicine have exposure and risk under the Emergency Medical Treatment Active Labor Act (EMTALA). Fines and penalties for violations can run into hundreds of thousands of dollars.

COVERAGE: Provides defense and indemnity up to $1,000,000 covering all legal fees and representation costs, fines and penalties if allegations of non-compliance are made against practitioners who provide emergency medical care.

 

PROGRAM FEATURES

• Up to 6 years retroactive coverage
• Payment of all fines and penalties up to $1,000,000 ($5,000,000 for groups)
• Coverage for all defense costs including attorneys fees, consultants, expert witnesses,
  reproduction costs and shadow audits, after $2,500 deductible
• Simple underwriting process (completion of a 3 page application)
• Average premium is $1,400-$1,600 annually per physician, discounts for groups
• Fast, no obligation quotes and approvals
• Underwritten by Lloyds of London