ZPIC Audit – Ten Recommendations for Audit Preparation
ZPIC Audit Introduction Has your Practice, Home Health Agency, Hospice, DME Company or PT / OT / ST Clinic been audited by a Zone Program Integrity Program (ZPIC)? If not, it may only be a matter of time. Despite your best efforts to follow Medicare’s directives, your organization may still be identified as an “outlier” by a ZPIC and subjected to a probe review or a full-blown ZPIC audit. Should you receive a request for records from a ZPIC, being prepared - in advance of receiving a ZPIC audit - can help ensure your organization’s compliance with applicable documentation, coding and billing requirements. The ...
5 Fundamental Medicare Compliance Concepts
Introduction to Medicare Compliance There are “rules of life” we have learned that can really bring certain essential Medicare compliance concepts into focus. While perhaps cliché, these sayings and principles can be quite helpful when explaining fundamental Medicare compliance concepts to new staff or non-compliance personnel. These 5 essential Medicare compliance concepts include: (1) “If it isn’t yours, give it back” Sound familiar? This is one of the first principles we are taught as children. Nevertheless, it is as true today as it was back then. Medicare providers have a legal obligation to promptly return any overpayments identified. In fact, with the passage of ...
AdvanceMed Reportedly Acquired by NCI
I. Background of AdvanceMed Transaction: AdvanceMed has a new parent. Last week, it was announced that NCI, Inc., one of the nation’s most successful information technology companies, had acquired the outstanding capital stock of AdvanceMed Corporation (AdvanceMed), an affiliate of CSC. While the acquisition went largely unnoticed by the health care provider community, the transaction may, in fact, be quite significant. With this acquisition by NCI, a recognized powerhouse in information technology, Medicare and Medicaid providers should expect AdvanceMed’s expertise in data mining and investigations to continue to grow. As AdvanceMed continues to fine-tune its data mining efforts and further expands its ...
SNF Medicare Denial Letters Follow HHS-OIG Report
I. SNF Medicare Denial Letters Background The Prospective Payment System (PPS) under which Skilled Nursing Facilities (SNFs) are reimbursed by Medicare has long been criticized by many concerned with curbing waste, fraud, and abuse in the Medicare program. Critics argue that, because the SNF reimbursement rate is prospective in nature and largely commensurate with the extent of skilled services provided to a beneficiary, SNFs will be more likely to provide unnecessary or unreasonable services for beneficiaries, thus increasing their reimbursement. For example, simply increasing the number of minutes of therapy a beneficiary receives (or providing a second or third therapy modality) could ...
2011. . . The Year of Compliance — Avoiding ZPIC Initiated Medicare Suspension Actions
(January 11, 2011): As you recall at the end of 2010 we identified the “Top Ten Health Care Compliance Risks for 2011.” The purpose of this and subsequent articles is to analyze two of those risks; Zone Program Integrity Contractors (ZPICs) and Payment Suspension Actions. Over the next few days we will be discussing these two risk areas in depth. I. Overview: As discussed in our “Top Ten” article, we anticipate that ZPICs will ratchet up their use of provider suspension actions in 2011. At the close of 2010, there already appeared to be an increase in the use of suspension ...
South Texas Health Care Providers Remain Under Considerable Scrutiny by HEAT Prosecutors and Investigators – Compliance Isn’t Optional – It’s Essential in 2011.
(January 6, 2011): Three Houston-area residents, one of whom is a physician, were sentenced to prison on January 4th for their roles in a multi-million dollar durable medical equipment (DME) Medicare fraud scheme. Each of the three defendants were also ordered to pay restitution to the Federal government, in amounts ranging from $29,052 to $1.4 million. I. Background of DME Fraud Case: According to DOJ, a Houston-area DME company improperly billed Medicare for power wheelchairs and orthotic devices, beginning in 2003 and continuing until late 2009. In addition to the three co-conspirators sentenced today, a total of eight other individuals were convicted ...
Top Ten Health Care Compliance Risks for 2011.
(December 31, 2010): In case you missed it, Congress, President Obama and the healthcare regulators had a banner year with respect to regulatory activism in 2010. Over the next several weeks we will be releasing a series of articles on our website addressing these dramatic changes and the compliance risks they present for your practice, clinic or health care business in 2011: Compliance Risk Number 1: Increased “HEAT” Activity and Enforcement: Perhaps the greatest risk to consider in 2011 is the increase in targeted health care fraud enforcement efforts by the government’s Health Care Fraud Prevention and Enforcement Action Team (HEAT). ...
Medicare Exclusion Screening of Your Staff is Essential.
(December 11, 2010): Earlier this week, HHS-OIG announced that it had assessed significant civil monetary penalties (CMPs) against a health care provider that employed seven individuals who the provider “knew or should have known” had been excluded from participation in Federal health care programs. These individuals were alleged to have furnished items and services for which the provider was paid by Federal health care programs. Medicare exclusion screening is essential. I. The Failure to Conduct Proper Medicare Exclusion Screening Activities Can Result in Significant CMPs. The provider paid $376,432 to resolve these allegations. As Lewis Morris, Chief Counsel to the Office of Inspector General ...
Number of False Claims Act Investigations Being Pursued is Currently at an All Time High . . . and is Likely to Go Even Higher Due to Changes to the False Claims Act Under Health Care Reform
(November 26, 2010): As set out in a U.S. Department of Justice (DOJ) Press Release issued earlier this week, during Fiscal Year 2010 (ending September 30, 2010), DOJ secured $3 billion in civil settlements and judgments in connection with cases involving fraud against the government. Notably, $2.5 billion (approximately 83%) of the recoveries were related to health care fraud cases. According to DOJ, since January 2009, $5.4 billion has been collected under the False Claims Act and returned to Federal programs (such as the Medicare Trust Fund) and / or the Treasury. As Assistant Attorney General of the Civil Division ...
The Zone 7 ZPIC Has Recommended Revocation of 82% of CORFS and 79% of CMHCs in South Florida – Is Your ZPIC Next?
(October 9, 2010): In late 2008, SafeGuard Services LLC (SafeGuard) was awarded one of the first two contracts to serve as a Zone Program Integrity Contractor (ZPIC) for Zone 7, an area which includes Florida, Puerto Rico and the U.S. Virgin Islands. The contract covered a base year plus four additional years. SafeGuard’s appointment was one of the first actions taken to consolidate the work previously performed by Program SafeGuard Contractors (PSCs) and Medicare Drug Integrity Contractors (MEDICs). Among its consolidated duties, SafeGuard is responsible for handling medical reviews and benefit integrity functions for Medicare claims under both Part A ...
ZPIC Audits
ZPIC Prepayment ReviewFrom LilesParker.com I. ZPIC Prepayment Reviews: Over the last year, Zone...
OIG Cautions About ZPIC Conflict of InterestFrom LilesParker.com ZPICs Have Conflict of Interest HHS-OIG recently released a...
Liles Parker Interviewed About SNF ZPIC AuditsMichael Cook and Robert Liles, partner and managing member of Liles Parker, respectively,...
Beware of HHA Compliance Risks in TX and OKI. HHA Compliance Background: Over the past few weeks, several important events...
ZPIC Audit – Ten Recommendations for Audit PreparationZPIC Audit Introduction Has your Practice, Home Health Agency, Hospice, DME Company...
Read More Posts From This CategoryMedicare Audits
Scrutiny Lingers for Texas HHAsI. HHS-OIG Report Concerning Texas HHAs. A recent report by HHS-OIG found...
Liles Parker Interviewed About SNF ZPIC AuditsMichael Cook and Robert Liles, partner and managing member of Liles Parker, respectively,...
Beware of HHA Compliance Risks in TX and OKI. HHA Compliance Background: Over the past few weeks, several important events...
MACs Flex Their Muscles with Recent CERT Audit FindingsI. What is a CERT Audit? The “Comprehensive Error Rate Testing” (CERT) program...
5 Fundamental Medicare Compliance ConceptsIntroduction to Medicare Compliance There are “rules of life” we have learned...
Read More Posts From This CategoryHEAT Enforcement
South Texas Health Care Providers Remain Under Considerable Scrutiny by HEAT Prosecutors and Investigators – Compliance Isn’t Optional – It’s Essential in 2011.(January 6, 2011): Three Houston-area residents, one of whom is a physician, were sentenced to prison on January 4th for their roles in a multi-million dollar durable medical equipment (DME) Medicare fraud scheme. Each of the three defendants were also ordered to pay restitution to the Federal government, in amounts ranging from $29,052 to $1.4... [Read more of this review]
Home Health Agency “Patient Recruiter” Sentenced to 63 Months in Prison for Allegedly Committing Health Care Fraud(October 18, 2010): The U.S. Attorney’s Office for the Eastern District of Michigan, working with the FBI and HHS-OIG has announced the sentencing of yet another defendant convicted of home health fraud. As the Department of Justice’s Press Release reflects, the defendant, a nurse who worked as a “patient recruiter“ and operator... [Read more of this review]
President Obama’s 2011 Funding Request Provides for Expansion of the HEAT Program to Additional Cities(October 4, 2010): As DOJ has recently noted in its own blog, over the last Fiscal Year, DOJ (including its 94 U.S. Attorneys’ Offices), HHS’ Office of Inspector General (HHS-OIG), and the Centers for Medicare and Medicaid Services (CMS), have been extraordinarily active in jointly pursuing health care providers allegedly engaging in fraud... [Read more of this review]
Medicare Fraud Strike Force Operation Leads to Charges against 94 Defendants, including 4 in South Texas(July 17, 2010): Yesterday, the Department of Justice (DOJ) announced charges against 94 physicians, medical assistants, and health care company owners and executives in connection with alleged false Medicare claims amounting to more than $251 million. 24 defendants from Miami account for approximately $103 million of that amount. Four defendants... [Read more of this review]
Texas Psychiatrist Indicted and Arrested(July 9, 2010): On June 14, 2010 the U.S. Attorney’s Office for the Western District of Texas announced that a Federal Grand Jury had returned a 99-count indictment against a pain management physician who operated clinics in San Antonio and El Paso. The physician was charged with 21 counts of health care fraud, 20 counts of false statements relating... [Read more of this review]
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