Safe in the Zone
The difference between agencies who are being terrorized by Zone Contractors and those who are safe in the zone should be obvious. You are safe if your agency has:
- Implemented a formal compliance program with outside, independent audits.
- Paid back money when errors were identified in your records and kept records
- Transmitted all of your OASIS data and the data was correct. ZPICs have authority to deny an entire claim if the OASIS is incorrect or not transmitted because OASIS is a payment requirement.
- Stayed aware of your agency’s numbers and kept them in line. If you routinely look at lengths of stay, HHRG’s, therapy use, and diagnosis coding, and they are in line with industry benchmarks you are safe. If there are one or more deviations, you may very well become a target but the end result will be okay.
- Invested in staff education for field nurses who provide the documentation for any type of audit.
If you haven’t been paying attention to these risk areas and you haven’t received a letter from your Zone Contractor yet, you may want to consider evaluating your risk. The outcome of ZPIC audits depends largely on two things – the content of the clinical records which and the way in which you handle yourself during an audit. If you are at high risk, then expect a letter and start the process now.
And for those of you who haven’t been following along, you are definitely at high risk if you:
- Have a length of stay greater than average (As a rule of thumb, look at your case mix report in the right column of the second page. Near the top it will have your average lengths of stay per time frame compared to reference mean. Look closely at the line that references percent of patients on service greater than 124 days. If 3 to 4 times higher than the reference mean you are in danger. Note the number on your case mix report is lower than actual because of duplicated admissions.)
- If the number of therapy visits is higher than normal. If all of your patients receive 15 visits, you might have a problem. If you have an excessive amount greater than 20 visits, you will definitely have a problem. If the vast majority of your patients are receiving therapy for multiple episodes or do not have a diagnosis that supports therapy, you may be a target.
- You have a bad state survey. Surveyors do not address payment issues but if they suspect that there are payment issues, they are instructed to refer the provider to the Benefit Integrity Unit which may request a ZPIC audit.
You have had a string of disgruntled employees. I cannot imagine a Zone Contractor acting on a single complaint. However, if documentation of fraud can be supplied by the single employee, you may be in trouble. Hint: Disable access to computer systems and charts prior to terminating a troublesome employee!
REALLY NO ONE KNOWS BECAUSE THERE IS NO STATUATORY REQUIREMENT FOR FULL DISCLOSURE. THE ZPICS USE TRANSITIONAL VERBS AND NON DESCRIPT TERMS SUCH AS ” COMPLIANT”. IF ONE WAS TO HEAR THAT A COMPLAINT WAS MADE AGAINST YOUR AGENCY ONE WOULD THINK THAT IT WAS A PATIENT OR REFERAL SOURCE. A COMPLIANT COULD BE FROM THOSE THAT ARE DATA MINING AND LOOKING AT BILLING TRENDS. COMPLAINT AND INQUIRY ARE ALMOST SYNONYMS WITH THEM AS WELL. TRULY THE REAL EVIDENCE IS WHEN THEY REVIEW CLAIMS. I HAVE SUBMIITED PERSONALLY AT LEAST 600 DETAILED RESPONSES TO THE ZPIC AND I CANNOT SEE ANY CORRELATION WITH THOSE THAT ARE PAID AND THOSE THAT ARE DENIED. TRULY , IT IS SCARY, I HAVE TO THINK THAT THEY DO NOT EVEN LOOK AT THEM. IT IS THE ONLY CONCLUSION I CAN COME TOO. THEIR DENIALS DO NOT COME WITH EXPLANATION SO EVERY OTHER ONE PAYS AND THE OTHERS ARE SENT TO REDETERMINATION FOR TRUE ADJUDICATION. SCARY AS THAT SOUNDS, IT IS MY EXPERIENCE WITH THEM . RESPECT THEM AND THEIR PROCESS AND GET OFF THE EDIT AS SOON AS YOU CAN. THEY KNOW WHEN THEY ARE NOT BEING TAKEN SERIOUSLY AND THAT TRULY IS THE KISS OF DEATH.
Danny, you couldn’t be more correct about the lack of rhyme or reason when it comes to paying claims in a ZPIC audit. But, I will say that with Zone audits specifically, they have something they are looking at prior to sending the letter of death. They have tons of money and the entire health care claims database to query. They look for statistical patterns that are a pretty reasonable assurance that the agency is doing something not quite right. I have heard agencies say that they discharge patients temporarily to lower their average length of stay. ZPIC’s pick up on that. The charts I have in my office are clearly being looked at for excessive lengths of stay. Some have very low visit rates, too. In addition, they are seeing if the patient has had claims for MD visits, pharmacy bills, hospital or outpatient care, etc. So, if an agency has patients on service for years and nothing significant happens to them, they are inviting scrutiny. If all their patients require therapy with a score of F1, they are looking for trouble. I have met too many people who really believe that the formula to making money in home health is to multiply the number of patients on service by the average dollar amount of the HHRG. Those are the only two numbers they look at and talking about discharging patients to these folks is like asking them to please rip out their liver without anesthesia and burn it in a ceremonial fire. And that’s fine with me. Because my good clients will have far less competition in a couple of years.