Present Risk Scenarios

Qui Tam

The Insured is an owner of a chain of urgent care facilities with locations in many states. Two qui tam lawsuits were filed against the insured alleging fraudulent billing for unnecessary allergy and flu testing.

The government also alleged that the facility inflated their billings for urgent care medical services (“up-coding”). The insured was reimbursed over $1 million in legal fees and was required to pay $10 million to settle the federal and state allegations.


Billing Errors 

The Centers for Medicare & Medicaid Services (“CMS”) conducted an audit of a physician for allegedly billing for services rendered to deceased individuals.  The CMS investigated and found the allegations to be true.

The CMS sought to suspend the physician’s participation in Medicare and Medicaid programs. The physician’s MEDEFENSE® Plus policy covered over $24,000 in legal expenses incurred in connection with the CMS investigation.


Stark Violations

The Office of the Inspector General (“OIG”) investigated the contracts, leases, and referral systems of a large healthcare system for potential Stark violations.  The OIG served several expansive subpoenas for records on the system in the course of its investigation.  The insured had underlying coverage in the amount of $250,000 through their med mal carrier and they also had $10 million in limits from NAS.

The insured retained counsel and vendors to respond to the subpoenas, incurring almost $1.5 million in expenses. After over two years of negotiations, the matter was resolved and the Insured paid the government $4 million in restitution.