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Centers for Medicare and Medicaid Services Puts Recovery Audit Contractor Program on Hold

4 Indest-2009-3By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

On February 18, 2014, the Centers for Medicare and Medicaid Services (CMS) announced it is in the procurement process for the next round of Recovery Audit Program contracts. This means the program is, for the time being, on hold while CMS awards new contracts. According to CMS, it will select new vendors to continue the Recovery Audit Contractor (RAC) program, which is responsible for detecting improper Medicare payments. It is expected that this pause will also be used to refine and improve the RAC program. In the announcement it was not disclosed how long the program would be on hold.

Click here to read the announcement from CMS.

This news comes months after CMS revealed an enormous backlog of RAC appeals. The backup is so bad, providers are not able to submit new cases until the existing backlog clears, which could take two years or more.

Current Contracts Extended to Conclude Appeals.

According to Modern Healthcare, CMS extended its contracts with the four current vendors until December 31, 2015, for administrative and transition activities. These contracts were to end on February 7, 2014. The purpose of the extension is to allow the RACs to handle and wind down appeals. To read the entire article from Modern Healthcare, click here.

For providers this means a lull in additional documentation requests (ADRs), however it is important to remember RAC audits are not going away.

Dates to Remember.

Providers should note the important dates below:

– February 21, 2014, was the last day a Recovery Auditor could send a postpayment ADR;
– February 28, 2014, is the last day a Medicare Administrative Contractor (MAC) may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration; and
– June 1, 2014, is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment.

Backlog of RAC Appeals Worse Than Ever.

The RAC appeals process has become so overloaded that in December 2013, the U.S. Department of Health and Human Services’ (HHS) Office of Medicare Hearings and Appeals (OMHA) notified hospitals, doctors, nursing homes and other health care providers that the agency would be suspending acting on new requests for hearings. Health care providers were told they would not be able to submit any new appeals until the existing backlog clears, which could take two or more years. To read more on the backlog of RAC appeals, click here for my previous blog.

RAC Audits Will Be Back.

In the first three months of the fiscal year 2013, RACs recouped more than $2.2 billion from providers due to what the RACs deemed were overpayments. With money coming in, RAC audits are not going away. It has become common for state and federal regulators to enforce even the smallest violations, resulting in investigations, monetary fines and penalties. If found in violation, you will not only have to pay fines and face disciplinary action, you will also lose revenue because you will have to spend time dealing with the investigation, instead of practicing medicine. Whether you are trying to prevent Medicare and Medicaid audits, Zone Program Integrity Contractor (ZPIC) audits, or any other kind of healthcare audits, there are steps you can implement in your practice today that may save you down the line. Click here to read more on self audits.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think about the RAC program being put on hold? What do you think CMS should do to improve the program? Please leave any thoughtful comments below.

Sources:

Kutscher, Beth. “CMS Recovery Audits on Hold as Contractors Wrestle Big Backlog.” Modern Healthcare. (February 20, 2014). From: http://www.modernhealthcare.com/article/20140220/NEWS/302209968/cms-recovery-audits-on-hold-as-contractors-deal-with-big-backlog

Centers for Medicare and Medicaid Services. “Recent Updates.” Centers for Medicare and Medicaid Services. (February 18, 2014). From: http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Recent_Updates.html

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2014 The Health Law Firm. All rights reserved.

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ZPICs Seek “Voluntary” Agreements from Physicians for Auto-Denial Edits for Home Health Services

MLS Blog Label 2By Michael L. Smith, R.R.T., J.D., Board Certified by The Florida Bar in Health Law, and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

According to the Centers for Medicare and Medicaid Services (CMS), the primary purpose of Zone Program Integrity Contractors (ZPICs) is to investigate instances of suspected fraud, waste, and abuse.  The specific actions employed by ZPICs to fulfil this mission include:

–  Investigating potential fraud and abuse for CMS administrative action or referral to law enforcement;
–  Conducting investigations in accordance with the priorities established by Center for Program Integrity’s (CPI) Fraud Prevention System;
–  Performing medical review, as appropriate;
–  Performing data analysis in coordination with CPI’s Fraud Prevention System;
–  Identifying the need for administrative actions such as payment suspensions and prepayment or auto-denial edits; and,
–  Referring cases to law enforcement for consideration and initiation of civil or criminal prosecution.

However, it appears that some of the ZPICs have been overly proactive in identifying the need for payments suspensions and are asking providers to voluntarily agree to payment suspensions for certain claims.

Click here to read more on ZPICs from CMS.

Physicians Being Targeted by ZPICs for Auto-Denial Edits.

Recently, physicians have been approached by ZPICs and asked to voluntarily agree to a payment edit on their National Provider Identifier (NPI) that would automatically deny any claim for payment for home health services that listed the physician as the ordering, attending, or referring physician.  A ZPIC requesting a specific physician to voluntarily cease ordering any home health services appears to go further than identifying the need for administrative action including a payment suspension.

The activities a ZPIC may use to fulfil its obligations to CMS are:

–  Request medical records and documentation;
–  Conduct interviews;
–  Conduct onsite visits;
–  Identify the need for a prepayment or auto-denial edits and refer these edits to the Medicare Administrative Contractors (MAC) for installation;
–  Withhold payments; and,
–  Refer cases to law enforcement.

The following functions are reserved for the MACs and not functions of the ZPICs.

–  Provider outreach and education;
–  Recouping monies lost to the Trust Fund (the ZPICs identify these         situations and refer them to the MACs for the recoupment);
–  Medical review not
–  Complaint screening; for benefit integrity purposes;
–  Claims appeals of ZPIC decisions;
–  Claim payment determination;
–  Claims pricing; and
–  Auditing provider cost reports.

While a ZPIC may refer a provider to the MAC for the imposition of an auto-denial edit, some ZPICs seem to have taken this process a step further and are attempting to have physicians voluntarily agree to the auto-denial edits.

Issues with Agreeing to an Auto-Denial Edit.

A physician who voluntarily agrees to an auto-denial edit could create significant problems for his or her patients and practice.  A physician agreeing to an auto-denial edit would need to cease ordering home health services and would need to refer the patients that need home health services to another physician.  Any physician that has been approached by a ZPIC seeking a voluntary auto-denial edit should consult competent legal counsel before agreeing to the auto-denial edit.

We have heard if ZPIC representatives allegedly intimidating or attempting to intimidate physicians who routinely order home health services for patients into agreeing to such auto-denial edits.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Have you heard of these auto-denial edit requests from ZPICs? Please leave any thoughtful comments below.

About the Authors: Michael L. Smith, R.R.T., J.D., is Board Certified by The Florida Bar in Health Law. He is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. http://www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

How to Speed Up the Medicare Prepayment Review Process

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

For Medicare providers, being notified of an impending audit is not welcome news. Being notified of a prepayment review is even worse. In a prepayment review, the health care provider must submit documentation to the Centers for Medicare & Medicaid Services (CMS) contractor before ever receiving payment. The health care provider will only receive payment (typically months later) if the contractor is satisfied with the provider’s documentation. This can be financially disastrous for the health care provider, who still must pay day-to-day expenses while waiting for a decision.

CMS Contractors.

If you have received notice of prepayment review, you first need to determine the contractor that has initiated the review. CMS contracts with four types of contractors:

– Medicare Administrative Contractors (MACs);

– Comprehensive Error Rate Testing (CERT) contractors; 

– Recovery Audit Contractors (RACs); and

– Zone Program Integrity Contractors (ZPICs).

Both the Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) can initiate prepayment reviews.

MAC Prepayment Reviews.

MACs will initiate prepayment reviews of health care providers suspected of improper billing for services. If the MAC detects anything resembling fraud during the process, the prepayment review can extend for up to a year or more. However, MACs will generally terminate the prepayment review when the health care provider demonstrates a pattern of correct billing. Health care providers who are notified of a MAC prepayment review should consult with an experienced health care attorney from the beginning of the process. An experienced health attorney will be able to assist the health care provider to ensure everything is in place for a speedy prepayment review.

ZPIC Prepayment Reviews.

A MAC may refer a health care provider to a ZPIC for a benefit integrity prepayment review if they suspect fraud. A ZPIC can also initiate a benefit integrity prepayment review based on data analysis.  Unlike MACs, ZPICs generally are less willing to communicate with health care providers about the prepayment review.

Additionally, there are different time limitations for a benefit integrity prepayment review. The MAC prepayment review is governed by Medicare Manual provisions that stipulate a maximum length of time on a prepayment review. However, a benefit integrity prepayment review can last indefinitely, if the basis for the review is not timely and properly addressed by the health care provider.

Further, ZPICs make fraud referrals to the Department of Health and Human Services (HHS) Office of the Inspector General (OIG). Thus, health care providers should view ZPIC correspondence as the start of a potentially larger investigation. An experienced health care attorney should be contacted immediately after a health care provider receives any contact from ZPIC.

How to Accomplish a Quick Review.

In many cases, the health care provider will be on Medicare prepayment review until its billing accuracy reaches a certain percentage. However there are other steps to help speed up the Medicare prepayment audit process.

1.  Read everything from the Contractor Carefully.

Pay close attention to all correspondence sent by the contractor. Make a note of the due date given and make sure your response is sent well within the time limits. Denials will usually occur if a response is not received by the given deadline. Also be sure that you send your response to the correct office.

2.  Read and Be Familiar with all Local Coverage Determinations (LCDs).

You should read and be familiar with any and all applicable local coverage determinations (LCDs) and national coverage determinations (NCDs) for any codes, services, supplies or equipment you are billing.

3.  Contact an Experienced Health Care Attorney Immediately.

A health care attorney who is experienced in prepayment reviews will be able to help you file a proper response in a timely fashion. An attorney will also be able to help find out additional information on why you have been placed on prepayment review and exactly what documentation the auditor is looking for. Alternatively, a health care consultant who has actual experience in working on Medicare cases and who has been an expert witness in Medicare hearings may be able to assist, as well.

4.  Contact the Contractor Responsible for the Review.

After you have consulted with an attorney, schedule a call with the contractor responsible for your prepayment review. During the call learn as many details about the audit as you can and find out what the reviewer wants in the documentation.

However, DO NOT:

  a. Argue with the auditor.

  b. Berate or demean the auditor.

  c. Challenge the auditor’s knowledge, competence or credentials.

  d. Ask the auditor to prove anything to you.

  e. Demand to speak to the auditor’s supervisor.

5.  Do Not File Duplicate Claims.

Keep track of all requests for additional documentation and when they were received. Do not think that you need to file another claim for the same items just because you have not received a response as quickly as other claims where additional documentation was not requested. If you provide duplicate claims, the contractor’s decision can be delayed.

6.  Keep all Submissions and Results Organized.

You must keep track of the date you receive the document request for a claim, the date you submitted the documentation for review, the result of the audit and the date the result was received. This will help you realize how quickly claims are reviewed. If a one claim’s review has taken longer than the others you’ve submitted, you can contact the reviewer to make sure they have received the claim and everything is in order.

7.  Follow-up with the Contractor for Feedback.

Keep in contact with the contractor throughout the review. This will help to maintain the relationship you initiated after first receiving notice of the prepayment review. This will also help you keep track of any issues and resolve them. Be sure to discuss how you can improve your claim submissions to meet the standards of your particular reviewer.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in prepayment reviews. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Sources:

Baird, Jeff. “Q&A with Jeff Baird: How to Prepare for and Survive Prepayment Reviews.” Home Care. (Sept. 13, 2010). From http://homecaremag.com/news/prepayment-review-faq-20100913/

Greene, Stephanie Morgan. “5 Steps to Get Off Pre-Payment Audit – Quickly!” Harrington Managment Group. (Mar. 18, 2011). From http://homecaremag.com/news/prepayment-review-faq-20100913/

About the Author:  George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

ZPIC or Medicare Audit and Site Visit Checklist

As a physician, medical group or other healthcare provider, if you receive a notice of an audit and site visit from Medicare, the Medicare Administrative Carrier (MAC) or the Zone Program Integrity Contractor (ZPIC), things happen fast with little opportunity to prepare. Hopefully this checklist will help you to prepare for the on-site visit that will shortly follow.

Many items on this checklist may seem common sense to the reader; however, they would not be on here if I did not encounter them as problems in at least two different instances for each one.

  1. Immediately check your address on the letter to ensure it is the correct and complete physical address of the site visit, including the suite number.
  2. Immediately call and make telephone contact with the auditors.
  3. Immediately call and advise your health care attorney and have him/her present at the audit and site visit.
  4. If the site visit is set for a branch office, make sure the appropriate administrative personnel and at least one of the treaters who see Medicare patients are in that office on the day of the site visit
  5. Conduct a self-inspection of your office immediately; call for an emergency house-keeping visit to clean if necessary.
  6. Make sure all displayed licenses and certificates are current.
  7. Make sure all patient health records are properly secured and your medical record handling and storage are complaint with HIPAA standards.
  8. Have a separate room set aside for the auditors to use with chairs and a flat surface (desk or table) for them to use as their meeting room, conference room and interview room.
  9. Make sure your office is “photogenic.”
  10. Require proper photographic identification and identifying information from each member of the audit team.
  11. Assign one main staff person as communication point with the auditors (and your attorney).
  12. Keep a copy of every document or paper you provide to the auditors during the site visit.
  13. Be aware of scrutiny of policies and procedures for narcotics or pain medications.
  14. If the records needed by the auditors are in a different office of the practice, don’t kill yourself getting them during the site visit.
  15. Don’t guess at the answers to the questions asked by the auditors.
  16. Expect to be asked for your drug list or formulary.
  17. Do ask questions of the auditors.
  18. Do not voluntarily advise the auditors of suspicions of wrongdoing or ask if what you are doing is correct.
  19. Keep good copies of and document your transmittal of documents to the auditors.
  20. If additional time is needed, request it by telephone and confirm it in writing.
Although this checklist just scratches the surface of the audit process, I hope you find it of some help in preparing for any upcoming audit involving a site visit.
 
For more information about ZPIC, Medicare, Medicaid or other healthcare audits, please visit our website at www.TheHealthLawFirm.com.

Have You Received a Notice of Termination of Your Medicare Provider Number?

Have you received a notice of termination of your Medicare provider number? Medicare has been revoking the Medicare provider numbers of many different Medicare providers including physicians, medical groups, home health agencies (HHAs), pharmacies, and durable medical equipment (DME) providers, based on returned mail sent to old addresses which have not been updated or based on inspection team site visits to old addresses.

Often the termination is retroactive to a much earlier date the change or move may have been determined to have occurred. Even if the mailing address is correct or was changed, the physical address of the business must have been updated, as well. It is usually an incorrect or old physical address which causes this to occur.

The effect of this termination includes:

    1. You are prohibited from reapplying to Medicare for at least two (2) years.
    2. You may have to pay back any monies received from the Medicare Program since the effective date of the termination (often many months prior to the notification letter).
    3. Other auditing agents may be notified such as the Medicare Zone Program Integrity Contractors (ZPIC) and the state Medicare Fraud Control Unit (MFCU).
    4. You may no longer contract with Medicare or anyone who does.
    5. You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.
    6. You may and probably will be terminated from skilled nursing facilities (SNFs) and home health agencies (HHAs) with which you have contracts.
    7. You may and probably will have your clinical privileges terminated by hospitals or ambulatory surgical centers (ASCs) where you have them.

What you should not do includes:

  1. Don’t bother to write letters.
  2. Don’t bother to call the Centers for Medicare & Medicaid Services (CMS).
  3. Don’t bother to call the Medicare Administrative Contractor (or MAC) (previously called the “carrier” or “fiscal intermediary”).
  4. Don’t bother to file a new CMS Form 855 (application) or a CMS Form 855C (change).
  5. Don’t bother to start communicating with CMS or the MAC about your situation and what you need to do about it.
  6. Don’t bother to complete and file the short, one-page Corrective Action Plan (CAP) form that is on the CMS or Carrier/MAC website (unless you are close to the deadline and don’t have representation; then you must.)


What we recommend is:

  1. Immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information. Then update or correct any incorrect information on you or your company, if you can. Print out the information as it existed before and print out the information after you have corrected it. (Note: Medicare will act shortly after the letter to you to terminate your access to this, so it may be too late).
  2. Hire an experienced health attorney immediately to assist you in putting together and submitting a comprehensive Corrective Action Plan (CAP), a Request for Reconsideration (RFR) and a request for an Appeal Hearing.
  3. Note that there is a thirty (30) day deadline for submitting the CAP and a sixty (60) day deadline for requesting an appeal hearing. Do not miss these.
  4. Implement formal, written internal policies and procedures to prevent a recurrence of the type of error, oversight or event that caused the termination. Train your management and staff on these.


The CAP should address every element of the applicable conditions of participation (COP) contained in the Code of Federal Regulations (CFR). It should include and be supported by all relevant documents, including but not limited to:

  1. Documents showing how the error occurred or past efforts to comply.
  2. Surety bond guarantees and documents (where required).
  3. Insurance coverage documents showing current coverage (general liability, professional liability, vehicle/auto liability).
  4. Current licenses and permits.
  5. Certificates of good standing and latest annual reports for any corporation or limited liability company.
  6. Print-outs from PECOS/NPPES Registry discussed above.
  7. Accident reports, insurance claims, police reports, fire reports or other documentation showing why a relocation was required (if this was an issue).
  8. Certificates of compliance training for you and your staff, if available.
  9. Copies of policies and procedures that you have adopted to keep there from being a recurrence of the situation that led to the termination.
  10. An authorization form for your consultant or attorney to represent you in the matter.


All copies should be clear, legible, complete, straight, no corners cut off an no handwriting on them, to the greatest extent possible.


Everything should be professionally assembled, typed, indexed and labeled. It should include a table of contents or an index. Number every page. It should be submitted to the MAC (or the agency/address given in the termination letter) by two (2) reliable means that document both sending and receipt. Keep copies of everything, including postal receipts, airbills, Federal Express labels, courier receipts, etc. It must be received at the address given in the termination letter you received (usually MAC) by the deadline given above. Keep copies of online tracking reports and return receipts.

In most instances, should you show a legitimate reason for the error, show you are currently in compliance, and show what remedial measures you have taken to keep there from being a repeat, the MAC will accept your corrective action plan (CAP) and will reinstate your Medicare number, as things stand currently.