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I have friends who can do just about anything.  Fans of Pinterest, Instructables, and the DIY Network channel can build a boat from water bottles, decorate like Martha Stewart and change out a faulty transmission on their lunch break.  There are Do it Yourself legal forms in case you want to write your own will and computer programs that serve as your personal accountant.  DIY healthcare includes sophisticated diagnostic testing and when you think about it, aren’t fajitas merely a DIY Burrito kit?

Following suit, is the Brand New Amazing Do It Yourself ZPIC from our friends at AdvanceMed.

Here’s how it works:

  1. You are chosen based upon statistical aberrations in your claims pattern.  One agency may be chosen because a certain percentage of patients have been on service for a very long time.  Another may be chosen because of the amount of therapy provided.
  2. A letter arrives in the mail.  It will have the name of a benign sounding company like AdvanceMed or Safeguard Services.  If you live in the Northeast, your Zone Contractor is listed as ‘Under Protest’ which I believe is a reference to the contractual agreement with CMS but wouldn’t that be a cool name for a Zone Contractor?  In spite of outward appearances, this is not junk mail.
  3. It references a list of patients and tells you to perform a review on those patients and assess for eligibility.  One agency had a list attached.  I believe they are the only one.  If you have seen a list, please advise STAT.  You may do so in a confidential email. You may have stumbled upon a rare document worthy of placement in the library of congress under glass.
  4. After completing assessment referenced in step 3, you are asked to send a report to AdvanceMed advising them of your findings along with a check to cover any overpayments.
  5. The letter goes on to strongly suggest that the agency stop everything and complete a 100% review of all records in their agency to assess for any compliance issues.

I regret that I was somewhat high the first time somebody actually read me one of these letters aloud.  The recipient of said letter did not find it as amusing as I did.  I promise to never take a work relating

After the meds wore off, it did occur to me that these letters could be very disturbing to an agency.  What exactly do they mean by a strong suggestion?  I strongly suggest that everyone exercises daily but many people do not and there is no penalty (other than heart attacks, strokes, obesity and diabetes).  I suspect that the Zone’s suggestion carries more weight than mine.  But, I have no way of knowing.

What really amazes me is the clever new reasons given for denials:

  1. No OASIS data found in the state repository
  2. ICD-9 Coding (Not new but the the focus is no longer on Diabetes and hypertension; it is now low vision)
  3. My favorite – the one I wholeheartedly concur with reads as follows:

Quality of care is questionable as the nursing visits were not increased to follow up on elevated blood pressure.

Another denial read the same thing substituting new meds for blood pressure.

If you are the recipient of a similar letter, please feel to call upon us for help.  If your agency does have the time and resources to drop everything and do a complete review of all clinical records, please email us anyway.  I am particularly interested in knowing if you received a list and what statistical aberration you reflect.

If you are not a recipient yet, it may be a good time to review all your validation reports since Jan. 1, 2010 and ensure that OASIS was submitted for all claims prior to billing.  You may also want to rethink your approach to care planning and get out of the 1W9 mode.  For information about coding low vision, check out The Coders blog.

I fully anticipate that the feds will be mailing letters to suspected drug lords asking them to perform a complete search of their home and report back with an inventory so that a sentence can be arranged.  I draw the line at DIY dentistry, though.


5 Comments Post a comment
  1. M #

    I just can not WAIT to get one of these little gems! WOW! That took some imagination on the contractor’s part.

    November 27, 2012

    • Color me like a fruitcake but I find it hysterical right up until I consider what might possibly be next. Please scan and send should receive one of these. I have friends who could use a laugh.

      November 27, 2012
  2. Danny Crudo. Pharm.D. M.S. #

    Thank you for the post. I have consulted with two HHC agencies and two DME/OXYGEN providers on ZPIC issues. All 4 were for ‘abbarent’ billing practices. 3 were full audits. One was ‘ 4-5 final billing episode requests. The only thing I would add is, if you get the requests from the ZPIC, stop billing until you know their requests are in and good. If it is a full edit, and transmissions just result in additional requests for information. In the case of DME THIS CAN BE HUNDREDS OF ADDITIONAL claims. Full edits take 4 months minimum to be taken off. If you think you are under a full edit with the zpics based on Medicare deposits halting and or requests for information I would do two things.
    Stop transmitting any claims
    Call the legal division of your professional association and or accrediting body

    November 27, 2012

    • I had two clients come to me after their received their ZPIC results and had their cash cut off. They were effectively shut down.

      If they wait for results unti they drop claims, it will be over a year. Again. Dead agency.

      Best advice….. stay OFF the radar.

      November 27, 2012
  3. Gail #

    When ZPIC can go back 10 years, how can older agencies who didn’t know they were doing anything wrong (i.e. keeping patients till Jesus comes back because they NEED us) “stay OFF the radar”?

    November 28, 2012

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