Home Health & Hospice Week

Why you should focus on 7 specific problems.

With the wide variety of compliance issues and audits that you have to worry about, you have one more added to the list -- Zone Program Integrity Contractor (ZPIC) audits. And ZPICs are increasing among home health agencies and hospice providers.

ZPIC audits tend to closely follow the target areas identified in the HHS Office of Inspector General’s Workplan -- which isn’t good news for HHAs and hospices, says attorney Robert Liles of Liles Parker PLLC in a recent blog post. The OIG’s recently released 2013 Workplan slammed HHAs and hospice providers with a proposal for "intense government scrutiny." ZPIC audits have expanded in scope and increased in intensity, and "have been focused on HHAs in Texas, Oklahoma, Louisiana and Florida," he notes.

Watch out: Unlike other Medicare audits, ZPIC audits are not random, according to a recent CMS Compliance Group blog post. "ZPIC auditors are selecting providers based on indication of potential fraud." The auditors conduct post-payment and pre-payment audits to root out Medicare fraud, targeting providers already suspected of coding and billing irregularities.

How Bad Could It Be?

Even if you’ve never heard much about them, beware that ZPIC audits are serious business. According to a presentation by Halcyon Rehabilitation, ZPIC audits have three potential outcomes:

1. Provider education -- this is the best outcome for a ZPIC audit, because you wouldn’t end up with an overpayment demand or other sanctions.

2. Referral to the Medicare Administrative Contractor -- the ZPIC could refer the audit results to the MAC for overpayment collection. If this happens, you can appeal the overpayment determination (see How To Win A ZPIC Appeal on this page).

3. Criminal or civil prosecution -- the worst possible outcome is that the ZPIC refers your case for criminal prosecution or civil litigation under the False Claims Act and imposes civil monetary penalties or other sanctions.

Beware: Auditors Look for These Problem Areas

"ZPIC audits of HHAs generally reveal two distinct problems: that patients are not home-bound and/or the services provided were not skilled services, and were therefore not medically necessary," Liles says. So home-bound status and unskilled services are definitely two areas you should examine to prepare for a ZPIC audit.

And according to Halcyon, you have a higher likelihood of a ZPIC audit if you have one or more of these "triggers:"

• Improper/inaccurate billing -- high claim rejection or recoupment rates;
• High clinical case-mix assignment;
• Higher utilization than neighboring providers;
• Certain Medicare admission patterns; and/or
• Length-of-stay outside industry norms.

Take 3 Steps to Ease Your ZPIC Worries

If you’re looking at these audit triggers and wondering whether you’ll soon get a visit from a ZPIC, you’re not alone. Here are a few things you can do to prepare for -- and survive -- a ZPIC audit:

1. Proactively review and update your documentation practices. Although you may overturn claims denials, you should reduce your risk of denials in the first place. "While ZPIC auditors excel at identifying reasons for denial, excellent documentation can prevent even the pickiest auditor from denying a medically necessary claim," Liles says.

2. Take a second look at home-bound status. Prepare your arguments for defending your patients’ home-bound status. "ZPICs interpret the relevant home-bound provisions to require that patients never leave their homes and are generally unable to get out of bed," Liles explains

But this is contrary to the rules, which require that patients have a "considerable and taxing effort" to leave the home, Liles points out. "Congress has specifically stated that attempts by home-bound patients to live a normal life (going to church, visiting family) that are rare or infrequent should not be penalized in non-coverage of claims."

3. Be careful about non-skilled services. ZPICs are especially stringent on non-skilled nursing services relating to medication management, health care education and diabetes care issues, Liles notes. "Oftentimes, ZPIC audits apply an extremely strict standard to what is or is not skilled care, and this is where appropriate documentation can make all the difference in the world." Action point: Ensure that your nurses are appropriately trained on the documentation requirements in your Medicare jurisdiction.