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HEALTHCARE Providers Should Hold on Tight - ZPIC Audits of Medicare Claims Are Increasing
The first 1 / 2 of 2010 has been hard on health care providers. With Recovery Audit Contractor (RAC) audits ramping up around the country, many providers have found that while RAC audits may be on their way, a far more pressing concern is represented by the Zone Program Integrity Contractor (ZPIC) responsible for auditing Medicare providers within their "zone." ZPICs are but among the commercial contractors hired by CMS to conduct the medical reviews of Part A and Part B health care providers. Over 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 that were initiated by PSCs, all of our recent cases have involved ZPICs.

As Montane Icarus Jacket Review and ZPICs have already been so quick to point out, they're not paid a percentage 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 a different fashion than are RACs.

It is essential to remember that both RACs and ZPICs are created 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 the majority of providers in the community (e.g. their peers).

ZPICs are responsible for conducting:

Medicare fraud investigations, including referrals to law enforcement;
Medicare data analyses (discovery, detection, investigation, and overpayment projection);
Medical reviews to aid 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 police; and
Medicare / Medicaid data matching program safeguard work for each state in their particular zone.
ZPIC Extrapolations of Alleged Damages:

Over the years, we've gone up against PSCs and ZPICs numerous times, challenging their interpretation of LMRPs / LCDs and assessing the techniques they utilized to engage in a statistical extrapolation of the alleged damages inside our client's cases. To provide these businesses their due - the statistical experts they employ are smart, aggressive and don't hesitate to respond when their methods have been challenged. We like this - it keeps us sharp.

By using some of the best statisticians in the united kingdom, in many cases, we've 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 in terms of facts, the methodology employed, and in the associated calculations conducted. As attorneys, we work with our experts to break down and assess the ZPIC's calculations. Perhaps they handled it appropriately - or maybe they didn't. There really isn't any way to know if it had been handled properly with out 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 have 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 prepared to answer any questions posed by the ALJ. Our recommendation - both counsel and their defense expert better prepare yourself. It's to never early to start considering how to best contest the extrapolation that has been conducted. Last of all, we are alert to numerous instances in which a provider (or their representative) has chosen to ignore the extrapolation as a contestable issue. Put 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 identified as a possible problem by way of a selection of other mechanisms), a medical review of their claims is often conducted by way of a ZPIC.

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

In giving an answer to a ZPIC's known reasons for denial, it is crucial that you obtain each and every reference relied upon by the contractor when denying the claims at issue. We've identified multiple instances where a contractor (not necessarily AdvanceMed) attemptedto apply an LCD retroactively. Moreover, it is very important examine the underlying statutory authority to determine whether the contractor's interpretation of a coverage provision is in keeping with the underlying law or regulation. Finally, it isn't enough to merely "poke holes" in the ZPIC's reasons for denial - we prefer to go one step further - show that the particular claims at issue do, actually, be eligible for coverage and payment. Should you learn that your practice or clinic is under review, we advise 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 healthcare 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/