ED Coding and Reimbursement Alert

Do you understand how this extra layer of investigation fits in the overall program integrity picture?

CMS is clearly delineating for ED providers and their billing agents the statutory mandate, mission, purpose and goals of the Zone Program Integrity Contractors (ZPICs) -- and if you're not up to speed, you're heading for audit troubles.

The ZPICs replaced the entities known as the "Program Safeguard Contractors", says Ed Gaines, JD, CCP Chief Compliance Officer for Medical Management Professionals, Inc, in Greensboro, NC.

The main focus of a ZPIC is detecting, preventing and referring potential cases of Medicare fraud, waste and/or abuse. "Fraud" may include but not be limited to the traditional notions of an express intent to deprive the Medicare program of funds. Under the federal False Claims Act (FCA), "fraud" may include situations where the provider or billing agent was "deliberately ignorant" or "reckless" about the truth or falsity of the claim filed to Medicare, says Gaines.

In an issue of MLN Matters® number SE1204 revised as of Feb. 24, 2012, CMS is clearly stating that the fraud may arise from the provider, the beneficiary and they specifically cite billing services as potential sources of fraud, waste and abuse, says Gaines.

Not CERTs or RACs: ZPICs are independent entities from Medicare A/B MACs, Comprehensive Error Rate Testing (CERT) contractors or Medicare RACs but they likely would coordinate with these contractors in certain instances, such as where a CERT contractor believes that abusive coding and/or billing practices occurred when conducting medical review.

Check Out This ZPIC Chart

There is a list of the current ZPICs and their respective zones of coverage in the MLM. Originally, CMS had stated that the ZPICs coverage areas would attempt to match the jurisdictions of the A/B MACs, but that does not appear to be the case today. ZPIC Zone 6 is presently under bid protest so no contractor is presently listed, says Gaines. (See Sidebar Table)

Get Familiar With Your Regional ZPIC

Providers and their billing agents or employees should be familiar with the names of the entities that have been contracted with CMS as the ZPIC for the Zones in which they practice or operate, Gaines advises. One way to do this is by visiting your ZPIC's websites of ZPIC to determine if there are sample letters it uses to communicate with providers--similar to the way some RAC contractors posted examples of their automated and/or complex review demand letters for general viewing.

For example: Posting a copy of the ZPIC sample letter along with the sample letter from the applicable RAC over the fax machines in the office is one simple way to remind those folks working the "post-billing" or back-end in case the provider is contacted by the ZPIC, Gaines warns.

Don't Get ZPICed for Medical Review

The ZPIC may also conduct more traditional "medical review" which generally means "medical record" or chart review, again where suspected fraud, waste or abuse arises.

In contrast to the A/B MACs, ZPICs may recommend that the MACs withhold reimbursements to the provider if there "creditable allegations of fraud.", say Gaines. This is a new provision in the PPACA that permits the suspension of payments--sometimes for multi-week periods--where the ZPIC or other investigator believes that there is a reasonable basis for fraud. Pre-payment reviews--truly one of the most onerous forms of medical review as it slows down Medicare reimbursements for multi-week or month periods--and on-site visits are within the ZPIC's "tools for the toolbox", he says.

Unlike the A/B MACs, the ZPIC will not conduct education or outreach, appeals of findings against the provider or actually recoup the over-payments; the ZPIC will inform the MAC and the MAC will recoup the overpayments, Gaines adds.