Your ZPIC is not a random pick

Your ZPIC is not a random pick

Last week, McKnight’s Long Term Care News ran a story that referenced a study conducted by the American Hospital Association which notes that there was a 22% increase in the number of medical record requests in the second quarter of 2012 than the first quarter. This is probably the result of the CMS’ March 2012 decision to allow RACs to request double the amount of medical records from skilled nursing facilities as they were previously allowed to.

We reported some news about ZPIC audits in July after the Office of the Inspector General issued a report on ZPICs, and now they’re certainly getting their moment in the spotlight. If you haven’t heard much about ZPIC audits, that’s not necessarily a bad thing, because one essential difference between ZPIC and other audits is that ZPIC audits are not random. ZPIC auditors are selecting providers based on indication on potential fraud, so we’ll pause here to provide a quick recap on what a ZPIC is all about.

What’s a ZPIC?

  • ZPIC stands for “Zone Program Integrity Contractors,” and replaces CMS’ “Program Safeguard Contractors”
  • These auditors investigate potential Medicare fraud by completing post-payment and pre-payment audits
  • ZPIC audits providers that are already suspected of coding and billing irregularities
  • They can perform onsite audits that are announced or unannounced, including interviewing facility staff and beneficiaries

One of the seemingly biggest issues is the pre-payment audit. The American Health Care Association has been one of the most vocal about this subject, and in a June 12, 2012 letter to CMS, it noted that these audits are “proceeding for unspecified amounts of time resulting in significant financial hardship for skilled nursing facilities with no formal process for a SNF to contest the prepayment review.”

A July Inside Health Policy article notes that providers have asked CMS to suspect the ZPIC program until some of the processes around this audit are clarified, giving credence to the American Health Care Association’s claim that skilled nursing providers may be financially harmed by these audits without a formalized way to dispute them.

It is commendable that there has been success in the past few years in recovering assets from Medicare fraud, and this trend is not likely to go away any time soon, as CMS continues to make its push against fraud. Until regulators formalize the processes for providers to encounter these audits, this topic will continue to be controversial and if your facility is contacted by a ZPIC auditor, you need to be prepared as to what that will entail.

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