 Escalating
Enforcement Activity
Since the early 1990s, the Federal
Government has made fighting fraud and abuse in the health care
industry one of its top priorities. Enforcement activities have
enabled federal agencies to prosecute and win record numbers of
cases. Settlements since 1996 have exceeded $3.5 billion.
Continued Spending
By law, the Attorney General and the
Secretary of Health and Human Services must establish a Health Care
Fraud and Abuse Control program. Since 1998, the budget for this
program has grown in excess of 15% annually. In addition, the
Federal Bureau of Investigation receives mandatory funding as part
of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
The government's budget is used to fund investigations of billing
fraud, STARK and EMTALA violations, and to fund future enforcement
of patient privacy compliance.
As a Result ...
Physician practices are increasingly
spending more and more time on complicated administrative and
regulatory issues. Here's how CAP plus
can respond:
| Medicare
Audit Coverage |
| Exposure: |
Governmental allegations of fraud |
| Cap
Plus: |
Provides
defense and indemnity coverage for physicians involved with
Medicare/Medicaid audits. |
| HMO
Audit Coverage |
| Exposure: |
HMO
allegations of fraud |
| Cap
Plus: |
Expands
coverage beyond governmental audits and provides defense costs for
HMO investigations for billing fraud. |
| STARK
Coverage |
| Exposure: |
Non-compliant
referral agreements |
| Cap
Plus: |
Extends
coverage to provide defense and indemnity (covering fines and
penalties) for providers that are investigated for allegations of
STARK violations. |
| HIPAA
Coverage |
| Exposure: |
Patient
Privacy Regulations
New rules governing the restricted use of patient information have
recently created a new liability exposure for healthcare providers.
Enforcement activity for non-compliance may become an additional
challenge for physician practices that are governed by these
regulations in the near future. |
| Cap
Plus: |
Provides
defense and indemnity protection for fines and penalties levied by
Federal or State enforcement agencies as a result of allegations of
HIPAA regulatory violations. |
| EMTALA |
| Exposure: |
Emergency
Medical Treatment Regulations
Physicians that are involved in the emergency medical care may have
regulatory exposure under the Emergency Medical Treatment Active
Labor Act (EMTALA). Fines and penalties associated with violations
of the act can run into the hundreds of thousands of dollars. |
| Cap
Plus: |
Provides
defense and indemnity coverage if allegations of non-compliance are
made against physicians who provide emergency care. |
|
