ZPIC Targets

Home Health and Hospice, as well as other post acute care providers have been under scrutiny before and this current emergence of ZPIC activity certainly won’t be the last time we are under scrutiny. But, unlike Focused Medical Review or even RACs, ZPIC audits begin with the presumption that the provider has committed fraud.

For our purposes, we will define Medicare Fraud as billing for services that were not covered under Medicare. Thats all the ZPICs are looking at – Billing. CMS instructs the ZPICs to refer serious quality issues to the state agency or QIO. In other words they do not care if your supervisory visits are made timely or if you followed orders and frequency. In fact, you may have had a stellar state survey and still find yourself in ZPIC sights.

To determine your risk level, first check your length of stay data on the top right corner of your case mix report from Casper. If your numbers are much higher than the reference mean, you may find yourself under scrutiny. If your average case mix weight is closer to three than two you are similarly at risk. Usually, high case mix weights are a result of therapy so be cognizant of how many of your patients receive therapy – especially when the number of visits is consistently at threshold levels. Finally, a high number of diagnoses that add to HHRGs can be suspect. If all of your patients have DM, you had better be able to explain why.

Hospices are looked at also for excessive lengths of stay and diagnoses that are not ordinairily terminal.

If your agency does not fit any of these profiles, you are most likely safe. However, the ZPICs have a lot of freedom to look at who and what they want. Multiple complaints to the Benefit Integrity Unit or state agencies may also spur an audit.

And remember, the vast majority of agencies will never undergo a ZPIC audit. But should you find yourself in the ‘zone’ at least you will have a place to start damage control.

As always, I welcome your comments and shared experiences below. And you can always email me.