When You are a ZPIC Target

With 128 known targets in the Louisiana, South Texas area, it may just be possible that your agency becomes a target. If that happens, it is not the end of the world. Remember, nothing happens fast in the Medicare world.

Obviously, the first thing that must happen is that clinical records must be copied or preferably scanned into electronic format. If, like the providers I have dealt with, the investigation likely stems from excessive lengths of stay, the charts will be quite large. Furthermore, the contractor will ask for all records for a given patient even if there has been multiple admits and discharges. Expect clinical records to exceed 500 pages or longer.

The next thing that you need to remember is that there is a very high probability that 100 percent of your records will be denied initially. This is the case regardless of whether your records are pristine or a train wreck. ZPICs examine charts with the intention of finding fraud. Targets are not chosen randomly and without reason.

When you respond to the contractor explaining why your records should not be denied, you will get the same response.

So, now you have waited months for two rounds of reviews only to be told that you will have a one hundred percent overpayment extrapolated for 36 months. If you can afford to give back three years of revenue, then read no further and relax.

On the third round of review with an independent contractor, the results may be a little better. This is the first real chance of having anything positive go your way but it won’t be enough. Your overpayment may drop from 100 percent to 70 percent but that is still a pretty high number. And at this point in time, that number is sent to your fiscal intermediary so that recoupment can begin.

But wait! There’s more! You have sixty days to ask for a redetermination with the Fiscal Intermediary. While generous, it is also important to note that recoupment starts at day 41 so it is truly in your best interest to not take advantage of the FI’s generosity. Requests for redeterminations must be at the FI within 30 days to prevent immediate recoupment and suspension of payment. While your case is under redetermination at the Fiscal Intermediary, recoupment will be delayed.

If you were close to retirement age when you first received the notice from the ZPIC contractor, there is a pretty good chance you will be receiving retirement benefits by now. Chances are it has been a year or more and nothing is settled yet

When the Fiscal Intermediary finishes its redetermination, the recoupment process will begin. At this point, you need to have someone who is very comfortable with Administrative Law procedures and knows each of your patients inside and out. There is a strong possibility that the ALJ will turn over a significant number of denials and your ordeal is over. There is also a chance that he or she will stand behind the original determination.

There are two more levels of appeals after the ALJ ending up in district court where cases are usually resolved at a level that the provider can afford. By this time you are tired and exhausted but usually at least partially successful. You have also spent a good deal of money on lawyers and consultants although not nearly as much as Medicare was requesting.

All along this process there are steps that you should take that will improve your chances of a satisfactory outcome and protect against future investigations. A consultant experienced in pre and post overpayment reviews will be able to assist you in doing this and a good health care lawyer will be able to help you in the latter stages.

If you haven’t received a letter from a Zone Contractor yet, it doesn’t hurt to put yourself in a position to reduce the risk of receiving unwanted mail. Look closely at the risk factors published Monday and evaluate your agency’s performance. If you haven’t already done so, implement a compliance program that ensures that your entire staff is dedicated to compliance.

If you have any questions about any kind of pre or post payment audit, please feel free to contact us or leave a comment below.