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Company May be on the way….

Lately, some agencies in Mississippi and Louisiana have been entertaining Zone Contractors.  They arrive at an agency and ask for 30 complete claims to be produced that day.  ZPIC activity is not public knowledge so I have no idea exactly how many agencies have been visited but it is substantial.  The ones that have come to my attention total approximately 15 locations with some providers sharing common ownership.

These agencies and the requested episodes are not chosen by mistake or randomly.  The Zone Contractors have been instructed to come up with innovative ways to detect billing patterns suggestive of fraud.  Before they arrive, they know which charts they want to review.   They may or may not visit the patient or the MD prior to their arrival at your agency.  There are rumors that I have been unable to substantiate that some staff members have been followed to determine if patients are visited and how long the employee stayed in the home.

How should you respond if visitors arrive at your office?  Here are my suggestions for what they are worth. 

  1. Do not panic.  They are contracted by Medicare and have every right to be in your agency.  They are there to do their jobs and no amount of attitude will get them to leave.  Be nice.
  2. Ask politely to see identification if they do not offer it right away.  Get the names of the individuals and write them down.  If they do not offer identification, call the Zone contractor for your area and verify that they are supposed to be there.  If you do not know the name of your zone contractor, look it up now and be prepared.
  3. Alert your administrator, your compliance officer and the DON that you have visitors.  Nobody else needs to know.  Quietly ask all unnecessary staff members to exit through the back door but advise them that they are to respond to any calls from the office stat.
  4. A list of episodes will be provided to you.  Assign one or two staff members to collect the documents and bring them to the DON or designee.
  5. The only review that is possible is a review for completeness.  Make sure that all notes are present.  If aide notes are missing, that is bad.  If skilled visits notes are missing do your best to find them.
  6. If you work at one of those agencies that is not above adding a date to legal document after the fact or signing someone else’s name, be aware that I have no use for your agency.  Also be very aware that you do not know what the Zone Contractor has already seen.  
  7. Number the pages and make two exact photocopies at the same time.  That way if something is missing, it is missing from both copies.  
  8. Ensure that senior management is present.  Nothing impresses your payor sources less than an owner or administrator who cannot be found while their agency is under fire.
  9. If you cannot locate visit notes or if upon a cursory review you find that claim should not have been billed (no signed orders or missed visits mistakenly logged as visits), back out the claim and include the paperwork with the information given to the zone.
  10. Do not make small talk with the Zone Contractor.  That pretty much never works out.

You do not have time to complete a clinical record review on 30 charts.  You will have the opportunity to supplement your information in the first two rounds of appeals and most agencies go at least two rounds.  Regardless of the quality of your records, expect a high rate of denials.  Also, expect that nothing will happen fast.

After they leave, go about getting caught up from what amounts to a day of not tending to your business.  Within the next week begin reviewing the photocopies you sent to identify your vulnerabilities.   Start supplementing documentation and gather supporting documents for any arguments you may produce.  When the results finally arrive, you will  be up against a deadline.

If your agency is blatantly fraudulent, get your billing caught up because the Zone can and will suspend payment if they find evidence of blatant fraud.  If your agency is not blatantly fraudulent, expect that within a year you may have your payment temporarily suspended for a few weeks after the second level of appeal and before an Administrative Law Judge.  Stack some bills now and get your creditors paid off in preparation for that time.

Remember, if things get tough, we can help you.  We have more than enough experience in appealing denials.  We have a great record with some clients and a pretty awful record with others.  You can probably guess what the difference is between the two groups.

16 Comments Post a comment

  1. Great Article as usual Julianne. I would add – that in the year or more that you await results – prepare/update your compliance plan. It is a protection/defense against fraud allegations. Remember – ZPIC’s are supposed to be investigating fraud. In all cases I have seen – no fraud was found but plenty of denials! With the extrapolation – all the cases we are working on are Millions of $$$ in payback.

    October 1, 2012

    • Absolutely, Liz. Corporate integrity agreements are supposedly not available for home health anymore but the best chance for significantly overturning results comes when the agency goes before an Administrative Law Judge. The ALJ is a human being and cannot help but consider any efforts the agency has made to improve compliance. It is the first and hopefully only chance an agency has to state their case before a live human.

      Not to blatantly plug your profession (cuz nursing is way cooler), there have been some interesting rulings from the Medicare advisory council after the ALJ level. Not being a lawyer, I do not fully understand them but apparently favorable rulings have been overturned. Anyone who goes before an ALJ without guidance from. HEALTH CARE attorney is taking a huge risk. It does not matter if your tax attorney or divorce lawyer is very nice. If they are good, they would not take the case.

      Also, it is worth adding that the last two ZPICs that I worked on had numerous math errors. For instance, AdvanceMed denied a single therapy visit because they did not see the order for it which was there. When Palmetto GBA tallied the results the entire episode was denied on their spreadsheet.

      Denials are rough. Extrapolation is fatal. CMS has some of the best statisticians in the country at its disposal. It is difficult to win against them unless you show where the data that was extrapolated was faulty. That’s actually kind of fun:)

      October 1, 2012
  2. Liz Chadwell #

    I am wondering if anyone is seeing denials related to the F2F documentation, either from the MAC, ZPIC or any other CMS reviewers?

    This is a great article with lots of useful advise……..thanks for sharing!

    October 1, 2012

    • I have seen episodes denied on face to face encounter. One episode requested by a client was a second episode. The face to face was not included. Another couple of episodes have been denied because the doc wrote one thing on face to face but it did not correspond with what the agency had. Example: hh for multiple sclerosis but the agency was actually changing foley cath and did not put MS as primary.

      October 1, 2012
  3. Gail #

    What’s with #3? I don’t understand that one? Thanks.

    October 1, 2012

    • Number 3 has to do with limiting the zone’s exposure to the staff. If I am walking through the door and a biller calls to me to fix my notes, I assume she means that I neglected to sign my name or something else that is easily corrected. A ZPIC investigator would hear the word ‘fix’ and it would end up on some report to the OIG somewhere. Also, depending on the size of your agency, you may have one or more disgruntled employees. Employees talk. I was in a client’s office last year when a ZPIC fax arrived. Before close of business I had three people email and text me to find out if it was true. I have met some dirty people in my day. The minute a certain type of competitor hears the zone is in your office, they may very well stop by to ‘share’ what they know. Finally, all you know is that the Zone is in your office asking for records. It is anxiety provoking to everyone. Find out what they are looking for, assess whether or not they will find it and then share the information with your staff. All that happens when they find out there is company is that anxiety sky rockets. Wait until you can give them something to do before you give then something to worry about. Your best employees can get a job anywhere. Don’t get stuck in a ZPIC with the employees less than best.

      October 1, 2012
  4. James Plonsey #

    I have seen agencies denied F-2-F. Some agencies failed to obtain one, others used checkboxes. My advise is to politely tell the ZPIC auditors you will send them within 30 days. This will allow you to make sure the entire record is correct. I have also seen denial for DME was ordered for patient(walker) but never delivered. Patients used husbands walker. Document, Document, Document

    October 5, 2012

    • So what your saying is that the Number the pulled out of the hat that day read no DME in contrast to MD F2F? I would add to your advice that agencies should send f2f regardless of episode sequence. Sometimes I think we’d get the same results if we stuffed old newspapers into an envelope and mailed to the Zone. I don’t think they had the inservice on how to actually approve claims.

      October 6, 2012
  5. Secret Admirer #

    Have you ever heard of a ZPIC audit which ended within a month with no denials and a letter for “educational purposes?”

    October 19, 2012

    • No, I have not. However, it does sort of scare me on behalf of the agency. If you have been following along with me, the Zone Contractors have come up with some new and different ways of doing things. In the past, there were two ways to win a ZPIC at the ALJ level. The first was with statistics. At this point, CMS probably has some of the best statisticians in the country working for them. Their numbers are good. The second reason was because agencies claimed that the MAC or FI did not educate them. Thus, they began sending out TIP letters to meet the educational requirements.

      You said the Audit was ended ‘with no denials’. I am not certain what that means. Does that mean that they got the paperwork back including discs with tons of data on it that went visit by visit and allowed them? Or does it mean that they were ADRs that were paid? In other words, the Zone Contractors now have a whole menu of options. They have been sending ADRs and visiting agencies on site lately. The agency visits are post pay and ask for a lot of records. The ADRs are prepay, obviously. Nowhere is it written about the ADR process for the Zone except that they have the right to request records. It does not say how long they have to pay, how they will choose the records and how many they will choose over which period of time.

      I would love to think the agency in question is out of the woods but I would not be satisfied until the agency received an overpayment letter with a 0.00 amount and a list of all the claims, visits, etc. I would also love to see the educational letter received. If there is anyway that you can get your hands on it and fax to me at 225-612-7012. I have no interest in knowing who the agency is. My goal is to ensure that all of us – you, me and everyone else with ten fingers and a keyboard, can anticipate what may be coming next and behave accordingly:)


      October 19, 2012
  6. Secret Admirer #

    In an earlier blog, you mentioned that an agency had only a “2% overpayment” according to a ZPIC audit. By “no denials” I mean there was a 0% overpayment determination. I can’t FAX you the letter, but I do know that the auditor who signed the letter was contacted by phone to confirm that no further action was to be taken by ZPIC. He confirmed that ZPIC “was finished with” the agency. Portions of the letter stated that “AdvanceMed has elected to educate your facility regarding the importance of ensuring beneficiaries receiving home health services meet the Medicare established home bound requirements, as previously defined.” Also a statement in the 5 page letter read, “To avoid the risk of future administrative action, AdvanceMed urges the agency to review all beneficiaries currently receiving home health services to ensure the eligibility requirements for medical necessity are met.”We also request that you be mindful of Medicare regulations when certifying and re-certifying Medicare beneficiaries to receive Home Health services.” There was also a warning to “be advised that failure to comply with HIPAA laws can result in civil and criminal penalties….” which referred to medical records being observed lying on a conference room table and unsecured records on top of a filing cabinet.
    At any rate, all “advice” is being taken very seriously including yours.

    November 1, 2012

    • I recently received a copy of a letter like this. To be quite honest, I fell out laughing. It appears to be a DIY ZPIC letter. The letter I received also stated that the agency was ‘strongly urged’ to do a complete review of all records and was given instructions on how to refund an overpayment. It was very thoughtful of The Zone to spontaneously offer free education.

      On maybe the third page of the letter I received, a list of patients was referenced. The agency was advised to review eligibility for those patients and submit a report to Novatis. Did the letter you are looking at say something similar?

      It sounds to me like the Zone is changing gears again as though they can’t decide what to do.

      Also the letter I received stated what percentage of the agency had patients on service more then 5 episode. To be quite honest, the number was very modest. But it does not correspond directly to other published numbers like mean and median LOS. To be honest I haven’t spent a lot of time looking yet.

      I will be posting on this after I get through some other work. You would think that if they wanted agencies to perform a DIY ZPIC, they would send a tool kit. Just saying.

      I would love to know how many of these letters have actually gone out and when. Anyone else who cares to share info, know that it will be greatly appreciated.

      November 1, 2012
  7. Secret Admirer #

    Interesting. On p. 2, AdvanceMed writes, we are “requesting that you reassess the beneficiaries on the attached list, and relay your findings regarding homebound status/medical necessity” to your fiscal intermediary. There is no time-frame or deadline and no perceived sense of urgency. Do you think this “change of heart” may have something to do with the recent “improvement standard” clarification? All of the audited patients have chronic, progressive, or debilitating conditions. So? What th’ heck is goin’ on?

    November 2, 2012

    • Did you actually get a list?

      It takes the zone approx a year to get results back to providers. I would go with that. JUST KIDDING!!

      Remember your job is to look for payment errors. So any charts that are found to be under billed should be adjusted as well.

      It does not give a deadline but you have exactly 60 days after finding an overpayment to adjust. Failure to do so means you will incur penalties, fines, interest and warts on your thighs. Work batches of charts from start to finish. Don’t do all initial reviews and then send them for approval, attain signatures for all charts, etc. for all charts at one time. You may not be through with all of them on day 60. But if you Work them in manageable groups, you will find overpayments in manageable intervals.

      November 3, 2012

    • I don’t know. I have no idea what is going on. I received yet another ZPIC result yesterday. It was 50k total overpayment. So my last three were all below 100. The first one was 60ish. We will get 30 back. The second was 1.9 but the math on their end was so bad that we won the extrapolation argument without even hiring a statistician. The one yesterday I honestly believe may have been related to the improvement standard limit. Without getting too much into detail for obvious reasons, these folks were all sick but chronically ill. Homebound wasn’t even a question. Heavily medicated, diabetes, hypertension, etc. You know how you see charts and all the patients have diabetes and hypertension and you think, yeah, right? Well, these guys had the numbers to prove it. Not a lot of changes in their plans of care.

      The bottom line is that they were sick. Services provided were not well documented but they were skilled. I figured we would get an overpayment of a billion dollars and win it on appeal with supplemental data. They probably saw the same thing I did and just paid up front.


      November 14, 2012

  8. Great article with lots of useful advise
    thanks for sharing!

    February 2, 2013

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