Medicare Compliance & Reimbursement

Make documentation back up your claims.

Present your arguments cogently to your Zone Program Integrity Contractor (ZPIC) auditor and back it up with documentation rather than getting daunted by the appeals process.

If you’re unfortunate enough to have an unfavorable audit, you should know that ZPIC appeals work in the same way as other CMS appeals processes -- except for the potential inclusion of Medicare fraud issues. Here are some tips for winning a ZPIC appeal, courtesy of Medicare audit defense and appeals firm Jackson Davis HealthCare:

• Submit all documentation. You must file all the required supporting documentation no later than the second stage (Stage II -- Reconsideration) of the ZPIC appeals process. Keep in mind that adding supporting documentation after this stage is extremely difficult. "When completing ZPIC appeals and ‘mock Medicare audits’ with providers across the country, we have found a number of hybrid medical record structures and significant challenges to submitting medical record documentation for review," the firm states.»
• Show your compliance with Medicare coverage criteria. "Several U.S. courts have held that a provider’s adherence to Medicare coverage criteria trumps all in the evaluation of claim denials," Jackson Davis points out.
• Link coverage criteria to your documentation. "Nothing speaks louder in the Medicare appeals process than providers that painstakingly tie Medicare coverage criteria to medical records documentation and present an evidence-based argument for payment," the firm says.