Notes

HEALTHCARE Providers Should Hang on Tight - ZPIC Audits of Medicare Claims Are Increasing
The first 1 / 2 of 2010 has been hard on healthcare providers. With Recovery Audit Contractor (RAC) audits ramping up round the country, many providers have discovered that while RAC audits may be on their way, a far more pressing concern is represented by the Zone Program Integrity Contractor (ZPIC) in charge of auditing Medicare providers within their "zone." ZPICs are but one of many commercial contractors hired by CMS to conduct the medical reviews of Part A and Part B healthcare providers. During the last year, ZPICs have already been taking over where Program Safeguard Contractors (PSCs) left off. While our firm continues to be handling several cases which were initiated by PSCs, all of our recent cases have involved ZPICs.

As PSCs and ZPICs have already been so quick to indicate, they're not paid a share of the Medicare overpayments identified like their fellow medical reviewers - Recovery Audit Contractors (RACs). Nevertheless, as you'll soon see, they're handsomely paid for their efforts, albeit in another fashion than are RACs.

It is vital to keep in mind that both RACs and ZPICs are designed to "find preventing waste, fraud and abuse in Medicare." Further, like their RAC cousins, ZPICs look at billing trends and patterns, concentrating on providers whose billings for Medicare services are higher than nearly all providers locally (e.g. their peers).

ZPICs have the effect of conducting:

Medicare fraud investigations, including referrals to police;
Medicare data analyses (discovery, detection, investigation, and overpayment projection);
Medical reviews to support fraud case development, including coverage and coding determinations;
Reviews, audits, settlements, and reimbursement of cost reports, and conducting specified audits;
IT systems activities for case and decision tracking and data warehousing;
Interface services with Medicare contractors, the medical community (outreach & education), and law enforcement; and
Medicare / Medicaid data matching program safeguard work with each state in their particular zone.
ZPIC Extrapolations of Alleged Damages:

Over the years, we've risen against PSCs and ZPICs numerous times, challenging their interpretation of LMRPs / LCDs and assessing the techniques they utilized to take part in a statistical extrapolation of the alleged damages in our client's cases. To provide these companies their due - the statistical experts they employ are smart, aggressive , nor hesitate to respond when their methods have already been challenged. We like this - it keeps us sharp.

Through some of the best statisticians in the united kingdom, in many cases, we have been able to show that their extrapolation of damages has not complied with applicable requirements, and is therefore invalid. To be fair, every extrapolation is different, both with regards to facts, the methodology employed, and in the associated calculations conducted. As attorneys, we work with our experts to break down and measure the ZPIC's calculations. Perhaps they handled it appropriately - or possibly they didn't. There really isn't any way to know if it was handled properly without a complete copy of their file (including associated work papers and calculations) so that we are able to fully assess their actions.

During the last year, we've seen a marked upsurge in Medicare ZPIC contractor participation (as "participants" much less "parties") in ALJ hearings. Their experts have consistently been professional, concise and ready to answer any questions posed by the ALJ. Our recommendation - both counsel and their defense expert better be prepared. It's to never early to start thinking about how exactly to best contest the extrapolation that has been conducted. Last of all, we are aware of a variety of instances where a provider (or their representative) has chosen to disregard the extrapolation as a contestable issue. Quite simply, they just accept the extrapolation as a foregone conclusion and focus solely on the claims. We strongly disagree with that approach. If we identify deficiencies with the extrapolation, we aggressively challenge its application.

AdvanceMed's Medical Reviews:

Once a provider has been identified as an outlier (or defined as a possible problem by way of a variety of other mechanisms), a medical review of their claims is frequently conducted by a ZPIC.

Several year ago, Kevin Gerold, CMS' former Acting Deputy Director for Program Integrity was quoted as saying that the agency had revamped its approach to claims processing in an effort to better "grasp the knowledge of the patient encounter." Mr. Gerold was further quoted as saying that CMS was going to "let medical reviewers assess a claim's legitimacy using the big picture of the individual encounter, not on a nit-picking slavery to master documentation." Unfortunately, inside our humble opinion, many ZPIC medical reviews have conducted have already been extremely technical - leading to the denial of many claims predicated on minor omissions, technical deficiencies and the contractors' own peculiar spin concerning the application of an LCD.

In responding to Montane Icarus Jacket Review 's known reasons for denial, it is essential that you obtain each and every reference relied upon by the contractor when denying the claims at issue. We've identified multiple instances in which a contractor (not necessarily AdvanceMed) attempted to apply an LCD retroactively. Moreover, it is important to examine the underlying statutory authority to determine if the contractor's interpretation of a coverage provision is consistent with the underlying law or regulation. Finally, it isn't enough to merely "poke holes" in the ZPIC's known reasons for denial - we prefer to go one step further - show that the particular claims at issue do, in fact, qualify for coverage and payment. In the event you learn that your practice or clinic is under review, we recommend that you immediately contact a skilled attorney to represent your practice and handle your defense.

Robert W. Liles, Esq., is Managing Partner at Liles Parker PLLC, Attorneys and Counselors at Law, a Washington, DC based law firm which represents health care providers around the country in ZPIC, PSC and RAC audits. For more information call: 1 (800) 475-1906. Also, see: [http://www.zpicaudit.com]
My Website: https://thenewestdeal.org/montane-icarus-jacket-review/