Home Health & Hospice Week

If you aren't taking ZPICs seriously, now's the time to change your attitude. One Texas home health agency has learned just how deadly a Zone Program Integrity Contractor audit can be. In an Aug. 25 letter, Zone 4 ZPIC Health Integrity informed the Texas HHA that it completely suspended its Medicare payments and the agency's payment suspension "may last up to 180 days ... and may be extended."

HI audited a "statistically valid random sample" of claims for 25 patients spanning 40 episodes, the letter notes. HI auditors also made site visits including patient interviews in the home in December 2009 and February 2010.

The result: HI found that six of the 25 beneficiaries were not homebound and that three of those six "did not meet Medicare requirements for skilled care," according to the letter. (See box, this page, for case examples.)

HI also based the suspension on "excessive outlier payments" made from August 2007 to July 2009, HI says. The ZPIC doesn't address whether the outlier claims were valid or not, it just notes that the agency received 52 percent of its Medicare reimbursement from them. That's compared to a national outlier billing rate of 5.76 percent. HI did not give prior notice of the suspension because it "involves suspected fraud or willful misrepresentation."

What happens next: In payment suspension cases, the provider has 15 days to submit a rebuttal statement and supporting documentation. The ZPIC then issues a determination of whether the payment suspension continues. "This determination is not appealable," the letter notes. If the suspension continues, "we will review additional evidence ... to determine whether claims are payable and/or whether an overpayment exists," HI says. Claims will continue to process during the suspension, funds just won't be disbursed. Once the payment suspension is lifted, payments will be applied toward any overpayment HI has determined