If your organization does not currently have a high-functioning compliance department, it’s time to rethink that decision. After spending the past 30 years collecting and analyzing outcomes data from internal programs (CERTs, HPMPs, QIOs, etc.), both Congress and CMS have committed unprecedented resources to enforce evidence-based coverage policies and stop Medicare fraud.
Having a defense is good: Having a great offense is better. In geographic areas where Zone Program Integrity Contractors (ZPICs) have been named, suppliers are spending hours (often resulting in overtime costs) chasing documents to respond to inquiries.
As a review, ZPICs are independent vendors hired by CMS to perform a specific function related to protecting the integrity of the Medicare Trust Fund. Their role was previously filled by Program Safeguard Contractors, who are being phased out. At press time, only three of the seven zones set up by CMS have awarded contracts to ZPICs. Yet stories about the havoc the ZPICs can wreak are many. The ZPICs are as follows:
- Health Integrity LLC for Zone 4 (Colorado, New Mexico, Oklahoma and Texas)
- Advance Med for Zone 5 (Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia)
- SafeGuard Services LLC for Zone 7 (Florida, Puerto Rico and Virgin Islands)
Sources say CMS has identified five target areas, including California, Florida, Illinois, New York and Texas. Texas providers have already been sharing horror stories about both the tenacity and sheer volume of these audits. Providers there who have faced this latest storm have been placed at times on prepayment review of all claims! It doesn’t take any imagination to understand the impact that has on an organization’s cash fl ow. Besides ZPICs having the ability to put providers on 100-percent prepayment review, ZPICs can bring other grim consequences.
The ZPIC audit’s most forceful difference is its potential Medicare fraud implications. If your organization is selected for an audit, it is not a random event. Something the contractor has determined to be “atypical billing practices” will bring him to your door. The auditor will normally already have data in hand and an agenda regarding what he wants to see. In the event the notice is in writing, a supplier has an average of 30 days from the date of the letter to get the information requested to the ZPIC. Subtracting the time the letter travels through the mail leaves the provider with about three weeks to respond. The demand for quick action coupled with the knowledge that ZPIC review consequences include payment denials, recoupment of overpayments and potential referral to other law enforcement agencies can result in added stress to an already overwhelmed reimbursement department.
The best prevention is an aggressive compliance program that identifies internal risks and recommends specific areas for improvement. The results and outcomes should be measurable. Some recommendations include:
Identify high-risk areas for evaluation. This includes equipment that has had multiple changes in local coverage determinations (LCDs), provision of services that are new to your organization and areas identified in the latest OIG work plan (See “The Government’s Plan for a Scam” in the March issue, Page 26.).
Review patient files to locate documentation that demonstrates the medical necessity as defined in an LCD and the related article. An LCD is always a two-part document, the actual LCD policy and an accompanying article. To ensure complete adherence, the supplier needs to review both. Remember, HME-generated forms, even if signed by a physician, do not fulfill medical necessity requirements. Notes from the physician office, hospital, skilled nursing facility, home health agency or outpatient clinic are considered part of the patient medical record and should be obtained and kept on file when possible.
If you find files (and you will) that lack the specified documentation, request it from the appropriate source. This will help you determine how long it takes to obtain these documents from your referral sources (sleep lab, primary care physician, hospital, etc.) and which referral sources put you at risk of noncompliance. Track the results. If you have a specific group that is notoriously slow, you will know to start with them in the event of an audit.
When you find areas for improvement, document an action plan in your compliance report. Then, follow up during the next reporting period to gauge improvement. If no improvement is made, change the approach your company takes to resolve the problem. Continue to monitor until the data demonstrate the plan has in fact worked.
Accept nothing less than excellence in terms of delivery ticket documentation. Ensure you have a qualified signature indicating date of receipt. All equipment and supply tickets should include product brand, model numbers, serial numbers and quantity delivered.
Spending resources now to build and maintain a compliance program will save your company not only money, but also several days of anguish should the government come calling. Better yet, such a program may keep them away all together!
