Home Health & Hospice Week

Like many home care providers nationwide, you soon could be the subject of a ZPIC audit. Such audits aren't an automatic death sentence, but you need to know the ropes to make it through.

Use this expert advice when a Zone Program Integrity Contractor auditor comes knocking:

• Call your lawyer. "I recommend that any organization that receives a ZPIC visit immediately contact a health care attorney," consultant Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas tells Eli. An experienced attorney can help you respond to the audit and keep information privileged.

"Take care before conducting an internal review of the claims requested," advises law firm Liles Parker, with offices in Washington, D.C. and Texas. "While an internal analysis can be invaluable, you want to avoid creating a non-privileged paper trail of identified problems. Remember, both ZPICs and RACs may make a referral to law enforcement if their assessment indicates that problems may be more than a mere overpayment."

Bottom line: "You should contact your counsel to ensure that your rights are protected while still fully meeting your obligations as a Medicare participant," Liles Parker says.

• Don't brush off a probe request. You may not even be familiar with your ZPIC's name, so you could easily ignore a probe audit asking for just a few files to review. That would be a big mistake, warns attorney Edward Vishnevetsky with Thompson Coe Cousins & Irons in Dallas.

The ZPIC's probe is your chance to head off a much larger audit and a possible payment suspension, Vishnevetsky explains. "If you get two letters, answer them as fully as you can so it doesn't go to a full-blown audit," he advises.

• Respond timely. Many audits return unfavorable results not because of the content of the documentation supplied, but because providers fail to respond in time, Vishnevetsky notes.

• Don't skimp on the documentation. "Provide all the documentation that relates to the request," recommends attorney Robert Markette with Gilliland & Markette in Indianapolis. "Your files should support the services you provided."

Make sure your documentation is written in "plain language" and is "detailed enough that regulators with little knowledge of health care, much less home care, can readily see" what you're trying to prove, counsels Washington, D.C.-based health care attorney Elizabeth Hogue. Auditors can always interpret things differently, but such documentation "makes it considerably harder ... for auditors to disallow payments for visits or to find that agencies engaged in fraudulent or abusive conduct."

• Organize your response. The risk of furnishing copious documentation to auditors is that they won't be able to find the pertinent information. Markette advises including a cover letter explaining how the documentation supports your claims. "I strongly recommend your attorney and your claims department work together on this letter."

• Plan for appeals. Review the reasons given for each denial. "Do not automatically assume the contractor's arguments are meritorious," Liles Parker reminds providers.

Keep a schedule of appeals deadlines. "Appeals must be filed in a timely fashion," Liles Parker says. "All supporting documentation and arguments must be submitted to the QIC."

"Be prepared to respond quickly," Markette urges in his blog. "There are specific timelines you have to meet to preserve your appeal rights. Failing to file your appeal in a timely fashion means you lose your rights to challenge the findings. Period."

• Forge an appeals strategy. Trying to fight the system in a ZPIC appeal hasn't been successful, maintains ZPIC audit consultant Tim Johnson with Jackson Davis HealthCare in Denver. Johnson has seen appeals tank when they contain legal arguments about why providers aren't subject to certain requirements, he tells Eli. Likewise for appeals with vague medical necessity assertions.

Instead, you should strive to show how the services on your claims adhere to Medicare's coverage and payment criteria, he advises. To get off a ZPIC's payment suspension, he recommends showing the contractor how you've changed your internal systems to better comply with Medicare coverage and payment rules.

• Don't give up all hope if you get socked with a whopping ZPIC denial. A physician practice in Tennessee recently got a $4 million ZPIC overpayment demand reduced to $2,810, reports the

Memphis Daily News. However, the appeals battle against AdvanceMed's denials cost VRF Eye Specialty Group $350,000, the newspaper says.