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Exposure

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.

HIPPA
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.

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