How to Avoid ZPIC Overpayment Assessments

100 dollar bills overpayment

One of the most stressful parts of a ZPIC audit comes when the auditors uncover ways in which your Medicare claims don’t meet coverage requirements. While you can file a redetermination appeal, it’s easier to avoid overpayment assessments altogether. You can do this by making sure that your whole team is fully trained in how to properly document, code, and bill Medicare payments.

Meeting Regulatory Documentation Requirements

It can be hard to convince clinicians and administrative staff alike that appropriate documentation practices are necessary, especially when there’s no threat of a ZPIC audit currently looming. Before an audit ever occurs, you need to show your staff that ZPIC auditors apply a strict interpretation of Medicare’s documentation and coverage requirements.

You can do this by sharing the published reports of ZPIC audits at other organizations. By showing them how ZPIC auditors apply Medicare’s coverage and documentation requirements, you can help them understand the need to adhere closely to these requirements.

Your staff should be able to understand and comply with documentation and coverage requirements for:

  • Local Coverage Determinations (LCDs)
  • National Coverage Determinations (NCDs)
  • Local Medical Review Policies (LMRPs)
  • The Medicare Policy Benefit Manual (MPBM)
  • The Medicare Program Integrity Manual (MPIM)

Other areas that your staff should be familiar with and strictly adhere to include:

  • any statutory provisions covering provided services, and
  • any additional guidance issued by Medicare that applies to your claims.

Make sure you and your staff go over recent enforcement actions and related concerns regularly. Read HHS-OIG’s reports so that you can learn from the mistakes of other providers in your position. Enlist the help of an attorney to help you keep your organization in full compliance, and address any areas of risk in your compliance plan.

As you might guess, ensuring that your staff understands all of these elements – and are compliant when it comes to documentation and coverage requirements – can be complicated. However, it’s important for everyone involved to understand the severity of consequences that can come with not understanding or being in compliance. Failing to comply and making seemingly minor mistakes can cost you your business – and cost everyone who works for you their job.

An Experienced ZPIC Audit Legal Team Can Help

Understanding and following all the elements of a ZPIC audit can be overwhelming and complicated. Combine this with the stress of what might happen to your business, and it can become an unbearable process. Fortunately, it isn’t something you have to navigate or figure out on your own. We can help. At Oberheiden & McMurrey, LLP, our attorneys have the experience and knowledge you need on your side to face and conquer any part of the ZPIC process.

To learn more about a ZPIC audit and what you can expect if documents are requested, you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

Navigating the ZPIC Appeals Process

zpic appeal

If your organization is the subject of a ZPIC audit, you could end up with millions of dollars in Medicare overpayments that you must pay back. But a ZPIC overpayment assessment isn’t necessarily the end of the story. You can appeal the assessment decision. However, over the past few years, the ZPIC administrative appeals process has become more and more complicated.  

The ZPIC audit by itself is complicated, and often overwhelming enough. After going through that arduous process, many business owners can’t even imagine tackling an appeal.

This is just one of the reasons you’ll need an experienced legal team on your side throughout the entire process. If not – at the very least – make sure you have someone to represent your business’s best interests when it’s time to appeal. Here are just a couple things you should know before attempting to navigate the ZPIC appeals process.

Bring Your Arguments Before an Administrative Law Judge

There are three levels of appeals that providers can file in order to challenge a ZPIC overpayment assessment. In our experience, it can be difficult to overturn a decision at the first two levels – the redetermination and reconsideration levels of appeal.

However, at the third level of appeal, you’ll have the chance to bring your case before an Administrative Law Judge (ALJ) who will be willing to hear you out regarding your arguments in support of payment.

Going into a hearing before an ALJ can feel very stressful, even though these men and women are typically fair-minded professionals who want to hear your reasons why the Medicare payments in question are valid. Of course, an attorney can speak for you at this hearing, which accomplishes two important things.  It takes a great deal of the burden off of your shoulders, and it ensures that your arguments are presented as professionally, efficiently, and persuasively as possible.

Hearings before an ALJ can also be complex. ZPIC representatives will be present, and also arguing their position before the judge. Other professionals, including statisticians, clinicians, and attorneys could speak on behalf of the ZPIC, especially if large amounts of money are at stake. An attorney will have the skills and knowledge needed not only to present your case in the best possible light, but to address concerns and arguments raised by the representatives of the ZPIC.

Speak with an Experienced ZPIC Appeals Attorney Today

You have a lot on the line, and you don’t want to risk it all attempting to navigate the ZPIC audit process alone. Even if you have already been audited and have received a decision, you might have other options, including the opportunity to appeal. Don’t risk making serious mistakes, or missing out on a chance to appeal the decision you’ve received from an audit.

To learn more about a ZPIC audit and what you can expect from the appeals process, you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

You’ve Received a ZPIC Denial Decision Letter – Now What?

denial decision letter

Few things are more stressful than a ZPIC audit, but finally receiving the denial decision letter is one of them. The receipt of a denial decision letter could mean that your organization is on the hook for potentially millions in Medicare overpayments. But don’t panic just yet.

Read the Letter Carefully

The first thing you should do when you receive a ZPIC denial decision letter is read the letter carefully. The ZPIC may specifically name the reasons for its denial decision. However, the audit process varies from one ZPIC to the next, and the letter may provide only general reasons for the denial decision. If the ZPIC doesn’t provide sufficient information about the decision in the letter, you may need to consult your attorney in order to discover why your claims have been denied.

It might be difficult interpreting the decision from your letter, so if you have any questions or concerns at all, it’s in your best interests to let a ZPIC attorney take a look at it.

Enlist the Help of an Attorney

Once you have determined the reasons why your claims have been denied – or if you cannot ascertain these reasons from reading the letter – it’s time to contact your attorney. The denial of claims may result in the recuperation of pending payments by your Medicare Administrative Contractor (MAC). You have 120 days to file a redetermination appeal. However, if you want to keep your MAC from confiscating your pending Medicare payments, you will need to file your redetermination appeal within 30 days of receiving the demand letter from your MAC.

Your attorney can help you establish a payment plan so that you can take full advantage of the 120-day appeal period, without risking the confiscation of pending payments by your MAC. It is important that you consult an attorney as soon as possible to ensure you have the best chance at appealing the decision.

Even if you haven’t had a lawyer assist you throughout the audit process, you’ll need one to help determine the best way to move forward. This could mean an appeal or other process that will be difficult to navigate by yourself.

Contact an Experienced ZPIC Audit Attorney Today

As you can probably guess, the best thing you can do is to have a qualified legal team on your side throughout the ZPIC audit. Once you have received your decision letter, you’re legal team will help determine your options. Let us plan your appeal and assist you and your business through the ZPIC audit process. You may have more options than you think.

To learn more about a ZPIC audit and what you can expect once you have received your decision letter, you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

Understanding the Ins and Outs of a ZPIC Compliance Plan

zpic compliance plan

If you’re a small-to-mid-sized provider practice and you don’t have a ZPIC compliance plan in place – you’re not alone. Many smaller providers become so overwhelmed with the day-to-day realities of caring for patients that they let building and implementing a compliance plan fall by the wayside. But drafting and implementing such a plan can help you be prepared for a ZPIC audit before such an audit ever takes place.

However, trying to determine where you should start can be complicated. To get you started, here are a few things you should know about creating and maintaining a ZPIC compliance plan for your business.

Make Sure You Avoid Fraudulent Activity

Although it might seem like an obvious element, it’s important that you, your organization, and your employees avoid any fraudulent activity. However, sometimes people can engage in activities considered fraudulent without even knowing it. This is just one of the reasons it’s important to have a plan in place, to protect your business and its employees. A ZPIC compliance plan is a strategy you can implement to stay on the right side of Medicare billing regulations, so that you can rest assured that no one in your practice is committing Medicare fraud, inadvertently or otherwise.

You need to put a ZPIC compliance plan tailored to the unique needs of your practice into place immediately. Section 6401 of the Affordable Care Act (ACA) requires all medical providers who wish to participate in the Medicare program to establish such a plan. If you have difficulty with any part of this process, you should consult a qualified attorney for assistance.

Compare Your Practices with Regulatory Provisions

First, review the statutory and regulatory provisions related to any services your practice bills to Medicare. Then, compare your actual documentation, coding, and billing practices with Medicare guidelines. Immediately take steps to fill any gaps between your practice’s billing, coding, and documentation practices and the Medicare rules regarding these practices. If you find an overpayment, you need to repay this money to the government within 60 days.

Before you perform an analysis of your billing, coding, and documentation practices, it’s a good idea to enlist the help of an attorney who can ensure that your internal review is accurate and your compliance plan effective.

Let an Experienced Attorney Help with Your ZPIC Compliance

Does your organization or facility have a ZPIC compliance plan? Chances are, you aren’t as prepared for a ZPIC audit as you might think. In order to protect your business, employees, and clients, you’ll need to ensure you have a qualified ZPIC legal team on your side from the beginning to the end.

Make sure you don’t make costly mistakes that can affect your business and its employees. To learn more about defending yourself against a ZPIC audit or if you need assistance filing a ZPIC appeal, you can contact the attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

Why You Shouldn’t Ignore a ZPIC Request for Documentation

zpic documentation

If a ZPIC requests documentation from your practice, it’s vital that you comply with that request. A ZPIC audit can be a scary and intimidating process. It might be tempting to ignore a request for documentation and just hope it goes away. But remember that ZPICs have an important function. They help prevent Medicare fraud, which makes care more accessible for those who need it most.

Also, it’s important to keep in mind that a request for documentation doesn’t necessarily mean you will automatically face negative repercussions. Sometimes, once you provide the documentation that is requested, any questions are answered, and you won’t have any other issues to address.

However, ignoring the request for documentation can lead to far worse problems, that you wouldn’t have necessarily had to deal with if you had just provided the requested information.

What to Expect from a Documentation Request

If you get a ZPIC request for documents, it will most likely be a two-part request. The first part will ask for records related to your business, such as:

  • Business contracts and agreements with other providers, physicians, suppliers, individuals, or businesses. Summarize verbal agreements in writing.
  • A list of former and current employees who worked for you during a specific period, along with information about them including hire and termination date, reason for leaving, title, qualifications, last known address, and phone numbers.
  • Any leases, medical director contracts, or employment agreements you have signed.
  • A list of your practice locations, including addresses and phone numbers.

The second section of the request will list patient records and dates of service to be audited. A ZPIC might request documentation on eight to 300 claims, or more.

What Happens If You Fail to Respond?

If you fail to respond to the request for records or documents, your organization can be suspended from participation in the Medicare program. The ZPIC can also recommend a revocation action against your organization. In the face of a request for documentation, an attorney can protect your organization’s best interests, help you get more time if you need it, and help you prepare the correct documentation for the ZPIC’s review.

Failing to respond to a request for documentation can only make matters worse. Further, you could end up facing serious consequences that you might not have had to face, including complete suspension from the Medicare program.

Speak with an Experienced ZPIC Attorney Today

As you can probably guess, the best thing you can do is ensure that you have a qualified legal team on your side. If you have been contacted about providing documentation for a ZPIC, you should call us immediately for a consultation. You don’t want to risk making serious mistakes or accidentally failing to provide the information requested.

To learn more about a ZPIC audit and what you can expect if documents are requested, you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

3 Reasons Medical Professionals Need Experienced Audit Attorneys

ZPIC audit attorney

As a medical professional, you’re busy with your patients and growing your practice. The last thing you probably think about is having a lawyer on retainer. After all, you aren’t doing anything illegal so why should you worry?

Unfortunately, when it comes to ZPIC audits medical businesses, things become more complicated. Even small errors can cost you your business and the reputation you’ve worked so hard to build. This is one reason it’s crucial that you have a qualified audit attorney on your side from the beginning. Other reasons you should consider keeping an audit attorney on your side include the following.

You Don’t Know What Your Staff is Doing

While your motto might be to provide the best care to your patients as possible, your staff might have other ideas. No matter how well you screen those that you hire, you can’t weed out everyone who turns in sloppy work, or people who write incomplete patient reports. Plus, you have your own work and can’t monitor every step your employees take. You might not be held responsible for these actions, but you could be, and your business could pay the price. An attorney can help you get through the process if your staff make errors that trigger an audit.

You Could be Audited at Any Time

Like nearly all medical professionals these days, you probably get reimbursed from some type of government agency, such as Medicare or Medicaid. With all the changes in regulations and rules, it can be tough to keep up while running a business. This can leave you and your practice vulnerable to action if you happen to be the subject of an audit. One of the most challenging aspects of being audited is that you will likely not be prepared and will need someone to guide you through the audit.

You Might Need a Buffer Between the Press

Even if you’ve done nothing wrong, there is a strong mentality of “guilty until proven innocent” when it comes to medical professionals. If you or your medical practice is the subject of some type of litigation or even a routine ZPIC audit, it could bring unwanted attention from the press. An attorney can not only speak on your behalf, but also help ensure that you retain your rights.

Even though your life as a medical professional is busy, retaining an experienced audit lawyer can be the best thing you do for your business.

Contact ZPIC Audit Attorneys at Oberheiden & McMurrey Today

Even if you don’t think you’ll ever be audited, it’s important for your business that you make the necessary preparations just in case. You could save yourself thousands of dollars in penalties, a ruined reputation, and a destroyed business by making sure you have an experienced legal team on your side. If you are being audited or need help with an appeal, contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

Agencies That Provide ZPIC Audit Oversight

ZPIC audits

You might have heard of ZPIC, which stands for Zone Program Integrity Contractors. It covers different regions, or zones, of the United States. The Centers for Medicine and Medicaid Services, CMS for short, created ZPIC to investigate potential waste, abuse, and fraud of the Medicaid system.

There are four companies that currently handle ZPIC investigations. Most of them cover two zones each, even though some zones are not contiguous. Here is an overview of the agencies that provide ZPIC audit oversight, and the zones they are responsible for throughout the country.

Zones Covered by ZPIC

The areas covered by each zone mostly contain states bordering each other, though a few of them are not consistent. For instance, Zone 1 contains California, Nevada, and a few Pacific islands while Zone 2 covers the Pacific Northwest, Central America, and Alaska. Although you might normally think Alaska and the Pacific Northwest would include California and end up in the same zone, in this case it isn’t.

Safeguard Services, LLC

Zones 1 and 7 fall under Safeguard Services, LLC. These zones include California, Nevada, Florida, Hawaii, and other US islands. California and Florida contain most of their offices with one of them in Puerto Rico. For those in California, however, this is the zone and the organization that is likely providing the audit oversight in your case.

NCI, Inc.

NCI, Inc. covers the rest of the Pacific Northwest, Alaska, most of central United States, and most of the south. They are one of the larger ZPICs with over 100 locations and 2000 employees and they perform more roles than auditing. NCI specializes in cyber security and other technological fields to assist in civilian and government protection. NCI’s headquarters is currently in Reston, Virginia.

Cahaba Safeguard Administrators

Cahaba Safeguard Administrators oversees Zones 3 and 6, which covers the northern United States and the northeastern seaboard states even though the company is based out of Alabama. CSA has been around for 70 years in total, and started as an insurance company before becoming a Medicare contractor 35 years ago. CSA has spent the last 15 years as a ZPIC with their specialization in statistical analysis to give auditors all the data they need for their investigations.

Health Integrity, LLC

Health Integrity, LLC, based in Maryland, protects the interests of Zone 4. This zone is by far the smallest in scope, protecting Colorado, New Mexico, Oklahoma, and Texas. Texas is renowned worldwide for their medical prowess, so they have their work cut out for them. Health Integrity, LLC includes a staff made up of experts who have a wide range of specializations and experience.

Experienced ZPIC Audit Attorneys at Oberheiden & McMurrey

A ZPIC audit can be overwhelming and scary. However, you don’t have to panic. Our attorneys have the experience and skill your company needs to successfully navigate a ZPIC audit. If you are being audited or need help with an appeal, contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

Not all attorneys of Oberheiden & McMurrey, LLP are licensed in California and nothing contained in here is meant to constitute the unauthorized practice of law.

3 Things You Can Do to Lower the Risk of a ZPIC Audit

ZPIC audits

Getting a ZPIC audit can be a taxing situation. Unfortunately, you can’t always avoid being audited. You can, however, take measures that can lower the risk of a ZPIC audit. If you find yourself part of an organization that is being audited, you and your medical practice may come out the other side unscathed. Even then, the entire process can still cause its fair share of stress. If you’d rather just avoid the trouble of a ZPIC audit altogether, there are a few extra precautions you can take that can help keep these legal problems out of your office.

Keep Your Staff Well Trained and Educated

Maybe you have an understanding of all the rules and regulations, but do your staff and coworkers? To prevent someone from making a mistake due to ignorance, it’s important to make sure everyone who works with you is aware of all the procedures and requirements. “I didn’t know,” probably won’t be a good enough excuse to an audit team, and it won’t look good on you, either. Make sure your staff members are not just well-trained, but continuously updated on best practices.

Follow Up Requests for Documentation

It’s easy to ignore paperwork when it comes in, but this can also cause you problems. If you get a request for any kind of documentation, it’s best not to put it off or ignore it. Keep paperwork and certificates up-to-date, so you’re prepared if you’re ever asked to present them. You’re less likely to be selected for an audit if you’re honest and prompt with requests for information and documents.

Self-Assess Your Organization

A great way to avoid being audited is simply to audit yourself. Keep an eye out for updates in regulations, make sure your Compliance Plan fits the bill, and if anything is out of place try to fix it as soon as possible. By keeping yourself and your staff in check, you could avoid getting audited in at all. Waiting until you get an audit letter to take a look at your organization’s practices is a recipe for disaster. Keep yourself organized now, and you’ll be well-equipped if you ever end up scheduled for an audit.

No one wants to have to deal with the frustrations of an audit. If you’re a medical provider, protecting your practice is probably high on your list of priorities. By taking these steps to keep the process at a distance, you can avoid stress for yourself and the people who work with you.

An Experienced Attorney Can Help with Your ZPIC Audit

If you do find yourself being audited despite the precautions you have taken, we can help you through the process. To learn more about defending yourself against a ZPIC audit or if you need assistance filing a ZPIC appeal, contact the attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

What Happens in a ZPIC Audit?

ZPIC audits

Unlike other types of audits, a ZPIC audit is not simply one that is random. Instead, the ZPIC is looking specifically for any instances or indicators that fraudulent behavior has taken place. If you or your medical practice has received notification that a ZPIC audit is impending, here’s a brief idea of what you can expect from the process.

Uncovering Fraud is the Priority

As you’re probably already aware, a ZPIC is not randomly looking for inconsistencies. Instead, he or she is focused squarely on fraud and any issues that might point to a willful intent to defraud the government of Medicare funds.

Requests for Documentation are Encompassing

ZPICs have been handed an enormous amount of power by the government. As government contractors, ZPICs can request your Medicare medical records and other documentation without specifying a look-back period. They are also not limited in the number of documents they can request. It isn’t unusual to hear of medical professionals receiving tens or even hundreds of such requests each day. For many facilities, just managing and complying with the document requests is overwhelming.

Data Analysis is Deployed

ZPICs have the latest in data analysis techniques at their disposal. They’ll probe samples, use statistical sampling, and analyze the data to reach conclusions about your intent. When it comes to a ZPIC audit, it’s much more complicated than just spotting a blatant act of fraud.

Interviews are Conducted

You can expect the ZPICs involved in your audit to conduct interviews with both your staff and your patients. They will likely ask pointed questions of your staff regarding your policies and processes when it comes to handling Medicare documentation. The ZPIC will also dive deep into your patient records to learn if a particular procedure was necessary or even performed as you have indicated.

Onsite Visits are the Norm

As part of the ZPIC auditing process, onsite visits without prior notice are to be expected. One way to prepare for this inevitability is to update your medical billing processes as soon as you’ve been notified that you’re the subject of a ZPIC audit. Be sure to have all your staff read it thoroughly and sign off on it.

Depending on the outcome of the ZPIC audit, further action could be initiated. This could include the withholding of payment, automatically denying claims, or referring your case to law enforcement. It’s important that you contact an attorney with experience with ZPIC audits to protect yourself and the practice you’ve built.

Experienced ZPIC Audit Attorneys Can Help

Although the process might vary depending on the practice and the circumstances, one thing that’s certain is that a ZPIC audit can be overwhelming and stressful. After all, your business and your livelihood may be on the line. An experienced legal team can help you navigate this process in the best way possible.

If you are being audited or you want to prepare for an audit, we can help. Contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

Four Improper Payment Protocols that Can Trigger ZPIC Audits

ZPIC audits

Medicare fraud is a complex and often confusing issue, both for health care facilities and for the government. Fraud cases aren’t always straightforward or easy to spot, and what’s more, they aren’t always intentional. When ZPICs audit and discover these cases, they often define them not as outright fraud but as abuse. Exactly where an audit falls on the spectrum of an innocent mistake to outright fraud can vary; most cases fall within one of the following four categories.

Outright Mistakes

Everyone makes mistakes. And when large amounts of billing and payments are involved, the risk of error increases. Numbers can be difficult to work with at the best of times, especially when computers are involved. It is possible for a billing specialist to cause an audit due to errors within the billing system itself. This includes entering the incorrect code, entering too many codes (e.g. duplicating a service accidentally), or failing to include any required details about the service provided.

Often, mistakes that occur at this level really are true mistakes. In fact, true mistakes happen more often than they should. They aren’t intentional, nor are they a result of the provider trying to fraudulently access Medicare. However, they are still considered illegal and actionable under Medicare guidelines. In any event, an audit due to a simple error can become much more serious than you might expect.

Inefficiencies and Waste

Providers are expected to optimize their services to best fit Medicare guidelines. Excessive waste or inefficiency is defined as anything unnecessary, or which could be provided under a more cost-effective claim. For example, ordering excessive diagnostic tests after previous diagnostics have already ruled out a diagnosis could be seen as a Medicare violation. Likewise, repeating services or offering services when they aren’t expressly required may fall under the same category. Unfortunately, inefficiencies and waste can happen because of simple errors as well.

Intentionally Bending the Rules

Providers who upcode or stack billing for a better payout may be at fault for Medicare abuse or fraud, too. This includes coding a claim for a slightly more expensive service even if you actually provided the lesser service instead. Every code must paint an accurate picture of the service provided.

Outright Deception

Outright deception is defined as anything the provider does for the express purpose of defrauding and abusing the Medicare system. This includes billing for services never rendered, piggybacking codes onto another claim, and any other situation where you request money from Medicare when it isn’t deserved. Intentional fraud audits are extremely serious, and if you find your facility or provider accused, it’s crucial that you contact an experienced lawyer for assistance immediately.

Contact Experienced ZPIC Audit Attorneys

Regardless of what causes the ZPIC audit, the process can be complicated and overwhelming. You have a lot on the line. Make sure you have a qualified ZPIC attorney on your side who can help you defend yourself against a ZPIC audit. Contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

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