Healthcare Philosophies, Culture and Protocol are Driving Process and Determining Outcomes.

Health care continues to evolve from the traditional/clinical to holistic, integrative.

Healthcare philosophies, culture and protocol are driving process and determining outcomes.

Structure of organizations are changing;

 Mergers and acquisitions , Vertically integrated health care models with hospitals,  outpatient facilities closely aligned with multi specialty groups, primary care and more creative solutions to try to solve the overarching goal of the affordable care act: 

 ▪︎improving quality

▪︎ increasing access

▪︎ and decreasing the cost of health care. 

 Paying attention to the election this coming year,  we hear proposals for national single payer or at least more large scale government subsided solutions to include more people and expand programs that bring health care to the under served.   And, More of our country will be entering retirement at a rate we’ve never seen before.

 These large government solutions will put extra burden on Medicaid.  And expectation is there will be continued cutbacks in reimbursement rates. 

the pressure on payers and out of control cost drivers include:

• Every day for the next 19 years, 10,000 baby boomers will reach the age of 65

• 49.9 million Americans are uninsured

• Medicare & Medicaid now insures 1 in 3 Americans 

 The government continues to work at their overwhelming success at recovering in fraud investigations.  It is important to remember that many of these cases involve health care: small to medium size privately owned groups that are doing their very best to keep up with complex billing details.

 Negligent billing can cost tens of thousands of dollars to an individual practitioner named in an investigation. Consider that during investigations receivables are frozen.

▪︎2017 – DOJ recovered over $3.7 billion from civil cases involving fraud and false claims.

• $2.4 billion involved the health care industry, including drug companies, hospitals, pharmacies, laboratories, and physicians

• Includes a $465 million settlement with Mylan Inc. for allegedly classifying the EpiPen as a generic drug.

  The doctors insurance agency has represented the doctor's company for 3 decades.

The doctor's company is the nation's largest physician owned Medical Malpractice Insurance company specializing in physicians health care organizations and facilities. 

 In 2009 the doctor's company enhanced their product to include important administrative medical coverage as the number of malpractice claims that resulted in medical board actions in all States increased to alarming numbers.

 Additionally,  hospital proceedings against these doctors emanating from what used to be a basic claim of medical injury resulting from alleged negligence now had reputation ramifications as medical boards in various States investigated.

Hospital privilige panels began inquiries and now the government and even private payers began to question the billing practices.

 The government responded by forming entities incentive sized to audit health care providers. 

RAC is an aggressive program that was created to find and prevent waste, fraud and abuse in Medicare and now, Medicaid 

Targeted classes of these investigations  include, but are not limited to: 

• All healthcare providers that have a National Provider Identification Number (NPI) issued by the CMS. 

Audits are conducted by third-party contractors — paid on contingency fee basis for over-payments they find.

 A successful three-year test program in California, Florida, New York, Massachusetts, South Carolina and Arizona collected over $900 million. 

This is a sample  of the different entities that started investigating as well…




• ICs

• MACs.

 Because the doctors insurance agency works with over 4000 physicians osteopaths the best practice providers and others, we are closely in touch with the number of investigations that are initiated. Physicians, nurses, hospitals, laboratories, nursing homes, social services agencies, pharmacies are all affected. 

 For over 10 years the doctors insurance agency has worked with The Doctor's Company and other specialty insurance carriers like NAS now Tokyo marine to bring sub limit or higher insurance limits by their unique policy called med defense.

MEDEFENSE® Plus is a uniquely effective insurance solution for healthcare providers facing many regulatory challenges, including Medicare and Medicaid billing errors investigations.

Complex regulatory requirements, as well as increased government scrutiny of medical billings, can distract providers from doing what they do best – taking care of patients. Medefense® Plus can help protect you against certain regulatory exposures and minimize the impact to your organization, so you can get back to business.


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