We anticipate that the Insured will incur an additional $25,000 in legal fees as a result of the OCR investigation. The costs associated with covering regulatory risks are a fraction of what it can take to clean up after an audit. 21 0 obj <> endobj 44 0 obj <>/Filter/FlateDecode/ID[<3C9541DD8B85412CAF11EC1398407E1B>]/Index[21 38]/Info 20 0 R/Length 107/Prev 69429/Root 22 0 R/Size 59/Type/XRef/W[1 2 1]>>stream It appears that the OCR complaint originated from a privacy breach reported by the Insured to the OCR in compliance with HIPAA. Suitable coverage could have helped protect these insureds’ time, money and reputations. The Insured received notice of a U.S. Non-Intervention Order that was filed as part of a sealed qui tam complaint filed in 2010 alleging multiple violations of the Federal False Claims Act relative to Medicare Claims.
As David detailed in his article, Medical Billing E&O – The First Thing Retail Agents Need to Know, there are several different entities that can audit healthcare professionals for billing errors or omissions.
As a result, the 11 Part B Billing Scenarios are specific to PTs and OTs.
The difference between the Billed amount and the Allowed amount becomes the Contractual adjustment. and regulations and with local medical review policies. © 2020 Ethos Insurance Partners All rights reserved. The Insured was served with two subpoenas by the Department of Health and Human Services/Office of the Inspector General requesting extensive and unrestricted production of paper and electronic records related to an investigation of Anti-Kickback and Stark violations. For whatever reason, they assume they’re not at risk for an audit, even given the additional regulatory exposures.
This upcoding resulted in the Insured being reimbursed at a higher rate. The case eventually settled for $1 million, $500,000 of which was fines and penalties. The Insured received notice of a Department of Health and Human Services, Office for Civil Rights complaint alleging that the Insured was not in compliance with the Federal Standards for Privacy of Individually Identifiable Health Information. MyLastApp is a trademark and the sole property of Ethos Insurance Partners. See the document titled "11 Part B Billing Scenarios for PTs and OTs" in the Downloads section below. Medicaid Services. We will update this Web Page to reflect changes in policy (for example, CCI edits, new codes, new coverage determinations) that impact therapy billing and/or to provide clarification on billing policy for PTs, OTs and/or SLPs. The Insured incurred $18,800 in legal expenses in responding to the QIO investigation. This can generally be placed on the same policy. While the records were recovered by the police within 48 hours, the Insured was required to notify the affected patients. When we use the term “Billing E&O,” it may not always be clear that the insurance product that can cover those “billing” exposures can also cover other types of regulatory proceedings that may have less to do with insured billing practices. Medical Billing Scenarios. Coverage is available not only for billing errors and omissions, but for regulatory penalties as well.
More specifically, the patient presented with an obvious act of self-harm, but the Insured failed to recognize or act on the patient’s psychiatric emergency medical condition.
WORKING IN MEDICAL BILLING AND CODING MEDICAL CODING MEDICAL CODING EXAMPLE Now is a very good time to look at a career in medical billing and coding. More specifically, the complaint alleged, among other things, that in addition for charging for the services rendered by clinical psychologists, the Insured also charged for services provided by nurses, technicians and other therapists even when such services were not “incident to” the clinical psychologist’s professional services. These stories illustrate the point that Billing E&O exposures can be far greater than what clients initially believe. Because the policies we sell often provide these additional areas of coverage, it’s good to note that the exposure is not just confined to billing errors and omissions. Reasonable and necessary: Program Integrity Manual Chapter 13, Section 5.1 3. The Insured retained counsel to assist with responding to the subpoenas. Contractor websites list local policies. EMTALA Proceedings (Emergency Medical Treatment and Active Labor Act).
Make sure to discuss the possible repercussions of not purchasing Billing E&O with your clients, and explain the different exposures they may have based on their specific risk profiles.
Thanks for subscribing to our newsletter. These may bring about several types of proceedings falling under the “Billing E&O” umbrella. To date, the Insured has incurred approximately $97,000 in legal expenses, PR expenses and notification costs as a result of the underlying privacy breach. Medicare Contractors (Carriers/ Intermediaries/ A/B Medicare Administrative Contractors) interpret Medicare laws, develop local policies, and educate providers.
The DHHS/OIG investigation is still pending, but Underwriters have already paid more than $820,000 in legal expenses and vendor fees. More specifically, the complaint alleged, among other things, that the Insured charged for pelvic ultrasounds, when the patient had, in fact, only received a bladder scan. As David detailed in his article, Medical Billing E&O – The First Thing Retail Agents Need to Know, there are several different entities that can audit healthcare professionals for billing errors or omissions. Your patient is using an inhaler. Qui Tam Plaintiff Proceedings (Federal False Claim Act). 7500 Security Boulevard, Baltimore, MD 21244, 11 Part B Billing Scenarios for PTs and OTs -- Individual vs. Group Treatment (PDF), Minimum Data Sets 2.0 Tool and Public Reports, Medicare Claims Processing Manual, 100-4, Chapter 5, Sections 10, 20, 30, 40, 100, Medicare Benefit Policy Manual, 100-2, Chapter 15, sections 220 and 230. In this medical billing term, it describes the amount of charges, a provider or hospital agrees to write off and not bill the patient as per the contract with the insurance company. The underlying privacy breach involved the theft of medical records for 12,000 patients from a storage shed.
The complaint sought damages of no less than $5,500 and no more $11,000 for each violation of the False Claims Act. Regulatory bodies are auditing for more than just billing errors and omissions now.
Nature of Risk: Orthopedic Hospitals, Outpatient Centers, etc. 11 Part B Billing Scenarios for PTs and OTs (Individual vs. Group Treatment), A federal government website managed and paid for by the U.S. Centers for Medicare & Coverage, Billing, and Financial Assistance for Foundation Medicine Tests 86% of patients have a financial responsibility of $100 or less for Foundation Medicine testing.1, 3–7 Insurance Coverage • All Foundation Medicine tests are covered for qualifying Medicare … billing and reporting capabilities •EMR: Electronic Medical Record •Software which allows ONLY case documentation for medical or behavioral healthcare. It is also alleged that the Insured entered into improper lease arrangements with the owners of such centers. h�b```e``��F3@��(���������� �dO���``��`��h I ��W@Z��A�1|�n � kX~h5�9���OHa|�Qrz�T���b�N��wan�Y����>H3�8,��@�0`��`�����-�� �e`���� ~� n endstream endobj 22 0 obj <>>> endobj 23 0 obj <. More specifically, the OIG is alleging that the Insured improperly referred hospital patients to MRI or outpatient centers owned by the Insured or owners of the Insured. The American health care system is modernizing just as a large portion of the pop-ulace enters retirement, and the demand for healthcare professionals who can process crucial data is growing daily. Here, we’ll go through five claims scenarios as seen by NAS, one of our leading markets for this type of insurance coverage. 11 Part B Billing Scenarios for PTs and OTs (Individual vs. Group Treatment) This page is designed to clarify existing therapy policy and to provide guidance on current Part B billing issues relevant to physical therapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs) and to the services they provide. In addition to paying the fines and penalties, Underwriters paid $92,000 in legal expenses.
Whether your insured is a large physician group or small clinic, they can be at risk for Billing E&O claims. h�bbd``b`z$���`;["8@�, ��"JA\7k#Hq�x"�Ab�@�OHo ��@�+H�˂�M� �:J endstream endobj startxref 0 %%EOF 58 0 obj <>stream Medical Billing E&O – The First Thing Retail Agents Need to Know, Surplus Lines Insurance: Understanding Taxes and Stamps, 3 Common Insurance Issues for Healthcare Providers Engaged In Clinical Research Services, 5 Ways Retail Agents Pay for Their Wholesale Insurance Broker, Nature of Risk: Senior Psychological Care. These claims are expensive, invasive and can turn into serious proceedings on several types of platforms. The OCR investigation is pending. 485.705, 484.4 2. Frequently, we hear about insureds who deem purchasing Billing E&O coverage for these audits unnecessary. The Insured received a letter from a Quality Improvement Organization (“QIO”) authorized by Medicare to review medical services provided to Medicare patients alleging that the Insured did not meet recognized standards of care in treating a patient in the emergency department of the hospital at which the Insured had privileges. Definitions of qualified therapy personnel: 42 C.F.R.