In addition to providing Medical Malpractice Professional Liability Insurance, The Doctors’ Insurance Agency works with physicians and surgeons nationally to protect their medical licenses.
The Doctors’ Company was one of the first insurance carriers to offer money (expenses up to $ 25,000, subject to a $ 1,000 deductible) to defend you against medical board or hospital/payer credentialing investigations.
This ‘sublimit’ was one of the INNOVATIVE COVERAGE SOLUTIONS first offered by The Doctors’ Company in response to a sudden increase in cluster claims brought by State Medical Boards in conjunction with the more expected and reasonable patient allegations of missed diagnosis or omissions (or other negligent service claims).
The limit was (and still is often - $ 25,000 – 30,000) by admitted carriers throughout the country.
This coverage protects against Regulatory actions or proceedings which require timely responses and experienced representation.
The ‘surplus lines’ policies (which are policies providing medical professional liability insurance for companies that are somewhat different or newer types of HCO’s. The limits for Regulatory actions can be lower ($ 5,000 ) with a policy limit aggregate of $ 25,000.
The types off ‘actions’ are administrative actions brought by Medicare/Medicaid, medical licensing boards, credentialing reviews and actions, Professional Review Organizations, Federal agencies regarding EMTALA, and the DEA. They are also brought by private payers.
This coverage at these lower limits do not add premium to the policy. The sublimits are included.
There are three main areas from which an administrative proceedings might be initiated:
a) State Licensing Board
b) Staff Privilege Inquiries (Managed Care Provider Organizations, Hospitals, etc.
c) Medicare, Medicaid Inquiry
The Doctors’ Company form for Defense Coverage for Administrative Proceedings:
The Company agrees…. , to reimburse the Insured for Legal Expenses incurred by the Insured arising out of a Disciplinary Proceeding first Instituted against the Insured during the Policy Period.
Disciplinary Proceeding: shall be limited to the following:
1. Any professional review action against the Insured by the professional review body of a health care entity with which the Insured has clinical privileges or membership, which action is taken for the purpose of adversely affecting said clinical privileges or membership. 2. Proceedings threatened or Instituted by a state health care licensing board against an Insured for unprofessional conduct. 3. Proceedings Instituted by a Professional Review Organization to impose sanctions on the Insured. 4. Proceedings Instituted by a state Department of Health Services or similar state agency, or the federal Department of Health and Human Services alleging Medicare/Medicaid fraud and abuse by the Insured, or performance of medical services in excess of, or in violation of, guidelines for appropriate utilization of said services.
Specifically, this insurance is to respond to ‘regulatory actions’: and, this is often coupled with Cyber (Technology Errors and Omissions or Stealing data)
You can accept your standard medical professional liability policy with the sublimits of $ 5,000 to $ 25,000 or you can purchase the higher limits so that the medical board coverage equals the limits off the professional liability insurance.
Billing (misuses or abuses)
Addresses Medicare and Medicaid utilization and billing review proceedings, including allegations of improper documentation involving overutilization, overbilling, unnecessary services charges, and “up coding.”
Covers state medical licensing board reviews involving potential sanctions for unprofessional conduct.
Covers credentialing reviews that may adversely affect existing clinical privileges, credentialing, or staff membership.
Provides protection for Professional Review Organization proceedings involving allegations of misconduct.
Regulatory Board Actions Defense
The Doctors Insurance Agency can also go to an outside market to purchase separate medical board defense insurance for you, these policies can take your limit up to 1 Million. When a patient or any review, oversight body complains or investigates a physician, your medical license at risk, it’s critical to have strong legal defense.
Regulatory Board Actions Defense defends your reputation and practice to help you get through these difficult regulatory proceedings.
This insurance provides coverage to defend your medical license and privileges from being revoked or restricted.
This is added to your professional liability insurance policy at no additional premium.
•$25,000 limit for legal defense in STARK, DEA, and other disciplinary or enforcement proceedings
When is a Physician at Risk?
A physician may be at risk of losing their license to practice medicine when an allegation of substandard care, unsafe behavior, insufficient record keeping, dishonesty, or other unprofessional conduct is made. Investigations can lead to disciplinary action against the physician, including large fines, costs, and license suspension or revocation.