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Posts tagged ‘ZPIC’


I admit that I was a little hopeful, if not disillusioned, when the new UPICs came to my attention.  After verifying that UPIC was not a ZPIC with a typo, I thought that maybe this was a special type of audit where you got to pick the charts you wanted to be reviewed like some people pick their own lottery numbers.  No such luck, I’m afraid.

UPICs are Unified Program Integrity Contractors.  UPICs will carry out program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching[i].  The primary objective of the UPIC is to identify fraud and abuse and make appropriate referrals.  Other agencies recoup overpayment and address recommendations to law enforcement addressing criminal or civil charges.  They can also recommend suspension of payment.  Whether or not the agency is notified in advance of the payment suspension depends on if the UPIC thinks it is possible that the provider will change it’s billing habits if it knows that payment will stop.  Think about that for a minute.  Who wouldn’t change their billing habits if they knew payment was coming to an abrupt halt?

UPICs, like ZPICs can request clinical records, verification of licensure, copies of claims, etc.  The most recent UPIC request I read included a host of new horrors that may not be available and/or are too cumbersome to send.   Here’s a short recap of some of the new things but remember, they can always ask for more or even go to your office to visit.

  1. Copy of the face sheet. I have never used this term in home health or hospice, but it is basically patient demographics and insurance information.  People who have experience in a hospital are likely familiar with this term.
  2. Copy of Medicare card and state identification card (driver’s license or state ID). The logistics of getting a copy of the Medicare card and state identification card involve too many opportunities for loss and theft that I don’t recommend it even if Medicare wants it.  However, Medicare and other payor sources lose money daily when somebody loans (rents) their Medicare/Medicaid card to someone else.  Some software systems allow you to post a picture of the patient on the face sheet.  DNA and fingerprints are not necessary, but the end of the earth is not too far to go if there are any doubts. 
  3. Authorization of benefits. This is almost universally included in the consent form given to patients.  Take a quick look and ensure that somewhere on the consent it says that the patient or representative authorizes the agency to bill Medicare for services.  It would hurt a lot if this statement was inadvertently omitted when all those changes were made to the form relative to the new Conditions of Participation.
  4. EHR Audit Trails. In most systems, these audit trails are cumbersome to obtain and require someone to print or save the audit trail for each individual document.  In one system, the audit trail can be over 100 pages for a single document.  For a long time, there was a vendor who provided audit trails on request, but the agencies were not able to run them.  If you get a UPIC, consider the burden to your agency and call the person who signed your UPIC letter.  It kind of makes paper charts seem appealing again.
  5. OASIS to include the start of care, the resumption of care certification prior to and after the dates of services noted in this request and the discharge. I’m not entirely sure what this means.  To the best of my knowledge, patients aren’t certified after Resumption of Care unless the patient was in the hospital at the end of the episode and there is no change between the recertification assessment (not mentioned) and the ROC HIPPS code.  If an agency has a reasonable hospitalization rate, this is a rare occurrence.  Plus, there are numerous other bullets in the list that mention OASIS assessments.
  6. Travel Logs. Some agencies don’t have travel logs.  Some don’t pay mileage and others pay a flat ‘trip fee’.  I would think a visit log would be more useful to the UPIC but in the two page request, that wasn’t mentioned.

There are many more entries in the UPIC request but even though the length of the list is daunting, it is repetitive.  Laboratory results are requested on page one and all diagnostic tests are requested on page two.  There are individual entries for all hospital documentation, Inpatient records, Inpatient records to support start of care, inpatient records for hospitalizations during the episode, emergency room visit notes and the history and physical.  The best advice I can give is to be careful when delegating the tasks on the list, so you don’t have multiple employees all printing OASIS assessments.

The good new is that most of you will not find yourself in the undesirable position of being the target of a UPIC. If you are one of the unlucky ones, well, it’s not luck that brought you the unwanted attention from a UPIC.  The data analytics are very sophisticated and there is nothing random about the selection of charts (which makes me wonder why a copy of your Medicare Census is included in the list of documents required from the agency.  They know who your patients are.)

That doesn’t mean that your agency is operating outside of coverage guidelines.  It does mean that cloned notes, poor coding, lack of OASIS skills and care plans that are copied from one episode to the next will be under the spotlight.  This results in paying money back to Medicare and additional scrutiny which may extend to your referring physicians who might then begin referring patients to your competitors because they don’t like attention from Medicare any more than the rest of you do.  I do not like it when care is provided to eligible beneficiaries gets denied because a nurse is a little too eager to show off his or her new cut and paste skills.  It’s not like the agency can recoup their paychecks.

Questions?  Comments?  Do you have any experience with UPICs?  Post your comments below or email us.  We need to know now so we can understand them before they become obsolete.

[i] From Noridian Healthcare Solutions


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.


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.


There comes a point when you are in this business long enough that you think you have seen everything.  Today I saw something that I never even thought existed.  A long term client received their ZPIC results from AdvanceMed.  In my life, I never thought I would see anything like this.   

Make no mistake.  This is a good client who acquired an agency several years ago and then called me to look at it.  I explained that most people performed due diligence before buying an agency.  As luck would have it, it was a great agency but once sold, there was nobody there who knew the business side of homecare and they were a little less than profitable.

So after a few months, a new administrator was hired.  She has an MBA but she sold drugs prior to accepting this position. (She will read this and get mad if I do not clarify that she sold pharmaceuticals.)  The only home health experience she had was well, frankly, none.

One of the first things I did was encourage her to pay her staff per visit instead of hourly because their overall productivity was about 2 visits per day.  That was a mistake.  I should have told her exactly how much to pay per visit.  But, I left that open and so she pays her nurses a ridiculously high per visit rate.  Her field nurses make more than I do and they only work three days a week.

And because they are down the bayou, their length of stay is about the twice the national average and they have a lot of therapy.  It is difficult to educate people who have never been to school and South Louisiana is known for its large Catholic families so lots of repeat teaching is needed as family members rotate in and out.   Two of their largest referral sources are orthopedic surgeons and as such an enormous amount of their patients require therapy. 

So what do these overpaid nurses with time on their hands do all day?  They talk on the phone and write stories.  They love the copy machine so they make copies of pretty much every piece of paper they can find and give it to people.  Then they call the people they gave them to just to be sure they got them.  They play with scissors and tape and send all these lengthy faxes to the MD with the med profiles taped on them so the doc can see everything they are taking.  I keep trying to show them how to cut and paste the meds on the faxes and remind them that even if the computer explodes, they will still be able to get to their documents.  I cannot begin to imagine what they spend on paper. 

Once or twice a week, they all sit down and have lunch together and talk about their patients in case conference.  This of course is documented.  It is rare that at least one or two nurses don’t come to the office to chart in the afternoons.  The geography is such that it makes more sense to chart in the office since they turn their notes in timely.  (What else do they have to do?)  In fact, some of the most entertaining reading I have done in the past year has been in their charts.  I am still on the fence about how much is appropriate to chart about the infected penile prosthesis but I know more than I wanted.

Probably the owners would take exception to their over paid, underworked employees but since they were making money they never really noticed.  And because they were paid per visit, it didn’t really cost them too much.

They are my only client who as had a deficiency free survey in the past several years.

And their ZPIC result?  AdvanceMed determined they were overpaid by a little less than 2 percent*.  

I am in awe. 

There are lessons here to be learned unless you are my client in which case, there is a well deserved good night’s sleep waiting for you.  Pleasant dreams.


*For those of you unfamiliar with the ZPIC process, most results are well over 50 percent and I have yet to see an overpayment assessed at less than a million.  This agency’s overpayment was measured in tens of thousands.

Medicare 101

We have a lot of challenges in Home Health next year.   No savior came to our rescue.  Congress has absolutely no reason whatsoever to overlook home health when cutting the budget.  They also  have every reason in the world to come after home health for fraud and abuse and they have with a vengeance.  They show no signs of stopping now and if you have been paying attention, nobody is safe.  I have clients with as few as 100 patients undergoing a ZPIC audit and we know that the larger companies are not excused from scrutiny, either.

So before you get serious about implementing new programs and creating new ways to improve care while reducing costs, spend a little to make sure that you as a nurse or you as agency are building upon a sound foundation that protects you if you find yourself under scrutiny.

Take the Medicare Quiz and when you are through, you will see your results immediately.  Let me know what you think of it.

Good Luck.


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