Topic: Zone Program Integrity Contractors (ZPICs)
Concern: ZPIC Audits
Question: ZPIC Audits—Are you ready???
In a statement by CMS, “The ZPIC program will focus on quick response to fraud and administrative actions. ZPICs may take action to ensure that Medicare trust fund monies are not inappropriately paid and that any mistaken payments are recouped. The fundamental activities of the ZPIC will help ensure payments are appropriate and consistent with Medicare and Medicaid coverage, coding, and audit policy and will also identify, prevent, or correct potential fraud, waste, and or abuse.”
With that being said, when they knock on the door, please understand, they come armed with information!! It is not random audits that they seek; rather they know exactly what issues they are tracking, and their status as CMS Program Safeguard Contractors provides them access to agency-specific billing patterns. Potential consequences of ZPIC reviews include: payment denials, recoupment of overpayments, and referral to other law enforcement agencies. This could be only the beginning of a long battle ahead.
If overpayments are identified, the MAC (Medicare Administrative Contractor) will send a demand letter for recoupment. If Fraud is suspected, immediate referral is made to the OIG: Office of the Inspector General (Did you know that they now host a Most Wanted Health Care Fugitive List???).
Extrapolation
The threat of extrapolation: the use of a statistical sampling to calculate and project the amount of overpayment(s) made on CMS claims, can keep providers up at night. The advent of the new era of audits, coupled with payment cuts and industry changes, represents quite a burden for those Providers steering their agencies through these troubled times. Many Providers are frustrated, generally feel unappreciated for the work they perform, and usually respond poorly to the litany of changes. Despite the rate of reforms, audits, and regulatory changes, Home Health agencies have nearly identical regulatory control as other Medicare Providers. CMS provides equity to all Providers by making available rules, regulations, and on-line manuals for use – everything you need to do in the home care industry is right at the tip of your fingers. It is, literally, in black and white, easily readable, and the author is puzzled when Providers are often overheard exclaiming “There are so many grey areas!!” Not really, in fact, not at all. When we start to buy into “home care mythology” or “that’s the way we have always done it” without being cognizant of contemporary rules and regulations, well that is where and when we lose the ability to forge the path of the future.
It is imperative to read all of the rules, follow the rules, and, most importantly, to train all clinicians on these rules. Quality Assurance and compliance plans are keys to staying current in the areas of clinical practice and education levels; regular monitoring identifies areas in need of better support and further education. It is easy to direct blame towards CMS and the auditors overseeing this Federal Benefit program, however, they do treat all Providers alike hold all when they expect us to follow regulations identified in the available publications, whether we read them or not.
In today’s expanding audit environment, Home Health is so much more than obtaining a referral, finding a clinician to see the patient, and worrying that if we hold clinical staff accountable for care quality concerns, they may become frustrated and resign. Providers cannot afford to adopt this outdated mentality when re-wiring care practices. Instead, all efforts should be made to continually propel both care and clinicians forward, to change the culture, and deliver contemporary health care to our patients. Use the audits to help your staff understand the changes from traditional Home Health approaches such as:
PAST – If it’s not documented, it’s not done.
CURRENT – If it is not documented thoroughly, if it doesn’t support reasonable and necessary, if it is not skilled, the patient is not homebound, and it took you several episodes to do the work, it’s so not done.
Read, Prepare, Audit Yourself, QA, Seek Assistance…They are ready…are YOU???
The HHSM Nursing Newsletter is written by Kimberly A. McCormick, RN/BSN, Consultant of HHSM. Her expertise is based on sixteen years of homecare experience.