ZPIC Audits Should Provide a Pause for Your Agency

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By Terry Miller 
Regulatory Advisor, McKesson

Look Closer at Homecare DocumentationAre your documentation and billing processes up to date? We know that the day-to-day running of your agency can be a challenge, and it seems that a break to look at longer-term issues never happens.

But as CMS finalizes the network of Zone Program Integrity Contractors (ZPICs) that are charged with uncovering fraud, waste and abuse, you need to make some time to ensure that your agency’s practices are in order.

The Recovery Audit Contractors (RACs) that you’re already familiar with deal with some issues of fraud. However, their primary mission is to make recommendations to reduce improper future payments to Medicaid. Suspected instances of fraud are reported to CMS. During the 2011 fiscal year, Medicare fee-for-service RACs collected almost $800 million in overpayments. In the first half of fiscal year 2012, nearly $1 billion has been collected from fee-for-service Medicare.

ZPICs are focused on the detection, prevention and recovery of fraud, waste or abuse to maintain the integrity of the industry. There is not much gray area between the honest mistakes that any agency can make and activities that are designed to defraud government payers. I know that the vast majority of agencies (like yours, I’m sure) have no intention of defrauding the government. But there are enough bad apples out there to make these enforcement efforts worthwhile for CMS.

According to testimony before Congress, the ZPICs that have been established saved $208 million during 2011 by denying improper claims before they were paid. Another $27 million in overpayments also was recovered.

Home care documentation is more critical than ever to ensure that your clinicians are following proper guidelines and delivering care at the right time and in the right manner to receive payment from Medicare and Medicaid.

But having home health software isn’t enough to keep the auditors at bay. From time to time, you need to assemble your management team and consider these questions:

  • Are we meeting the expectations of payers and patients?
  • Is each step in the intake, care and billing process necessary and valuable to the patient and the agency? What needs to be re-evaluated, changed, scrapped or tweaked?
  • Are we following our own policies and procedures?
  • Where is the industry going, and is our agency going in the same direction?

If you haven’t thought about these questions recently, the rise of ZPIC audits should provide the impetus you need to start thinking about them.

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