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.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results cannot guarantee a similar future outcome in your case. Oberheiden & McMurrey, LLP is a Texas LLP with headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.

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.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results cannot guarantee a similar future outcome in your case. Oberheiden & McMurrey, LLP is a Texas LLP with headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.