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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.

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