RAC Audit Appeals | ZPIC Audit Appeals | UPIC Audit Appeals
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Over the past decade, CMS has ramped up efforts to guarantee the taxpayer that healthcare providers are solely paid for services rendered that (1) meet requirements as originally established within the Social Security Act and subsequent regulations; (2) meet Medicare provider contractual obligations (Conditions of Participation); and (3) meet Medicare coverage criteria.
CMS spent 30 years collecting and analyzing outcomes data from internal audit programs (CERT, HPMP, QIO, etc.) and both Congress and CMS have committed unprecedented resources to enforce evidence-based coverage policies and stop perceived Medicare fraud. In an effort to move-the-bar and collect on overpayments to providers, the federal government is taking aggressive strides to accelerate the acceptance of evidence-based health care and lighten the load of a strained national budget. The modern Medicare auditing effort is both far reaching and technologically advanced. Law enforcement, Medicare Recovery Auditors (RAC Audits), Medicare Administrative Contractors (MAC audits), Zone Program Integrity Contractors (ZPIC Audits), the Office of Inspector General (OIG) and a host of others are coordinating to crack down on and eliminate fraud.
CMS is investing hundreds of millions of dollars to force providers out-of-business and into complying with Medicare rules & regulations. The target? Everyone. In addition to now having thousands of contracted individual Medicare auditors under the CMS umbrella, the government is utilizing leading-edge database technology and integrated business logic to assist in the day-to-day review of millions of electronic Medicare claims for payment. Providers can no longer fly under the radar of the Medicare audit process. If you submit electronic claims for payment, you are instantly being “audited” for the services rendered. The problem? The vast majority of healthcare providers are good people that obey the law and make every effort to adhere to multiple layers of conflicting and seemingly arbitrary Medicare coverage criteria for payment. While for-profit, Medicare audit contractors are building businesses and selling out to the highest bidder, providers are caught in a giant web of never-ending Medicare audits of their services. Hospitals, physicians, home health agencies, hospices, skilled nursing facilities, inpatient rehab facilities, physical therapists and HME suppliers.... all are facing daily challenges of operating under enormous governmental scrutiny and overwhelming paperwork requirements.
Now, more than ever, Medicare contractors are applying subjective opinions and inaccurate criteria in order to insure preconceived outcomes. Great providers are being bankrupted and thousands of people are losing their jobs to unscrupulous auditors that are just trying to make a buck and increase their company's stock price.
CMS defines the Recovery Audit Program’s mission as “… to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries…”.
The nationwide Recovery Audit Contractor (RAC) program started in 2005 with a targeted demonstration project in select states across the U.S. (i.e. California, Florida, New York, etc.). The demonstration ran between 2005 and 2008 and resulted in almost $1B in perceived overpayments being recouped from providers. As a result, Congress adopted the permanent, national program under Section 302 of the Tax Relief and Health Care Act of 2006.
There are currently 4 Recovery Audit Contractors and each is responsible for identifying overpayments in their respective jurisdictions. The Recovery Auditor in each region is as follows:
Region A: Performant Recovery
States: CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI and VT.
Region B: CGI Federal, Inc.
States: IL, IN, KY, MI, MN, OH and WI.
Region C: Connolly, Inc.
States: AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA and WV
Region D: HealthDataInsights, Inc.
States: AK, AZ, CA, HI, ID, IA, KS, MO, MT, ND, NE, NV, OR, SD, UT, WA and WY
While the Medicare Recovery Audit Contractor program (RAC Audits) continues to focus the majority of efforts toward hospital adoption of Medicare coverage policies, CMS has launched another major initiative to directly challenge all other providers. Although the program - Medicare Zone Program Integrity Contractors (ZPIC audits) - was not officially rolled out with an emphasis on physicians, home health agencies, hospices, skilled nursing facilities, DME suppliers and physical therapy billing, that is exactly where it has been focusing efforts.
Across the southeast, south central, midwest, northeast and west coast regions of the U.S. - ZPIC auditors are in full force. SafeGuard Services, AdvanceMed, Health Integrity and Integriguard are all pursuing providers with surprise on-site visits, targeted data analysis, random audits, 100% pre-payment holds, extrapolations and follow-up to whistleblower actions.
So, who are ZPIC auditors anyway? Zone Program Integrity Contractors are organizations hired indirectly (or in connection with other CMS affiliated contractors) by CMS to perform a wide range of medical review, data analysis and Medicare audits. While ZPIC audits are similar in many ways to other Medicare audits currently being performed nationwide they do differ in one very important aspect – potential Medicare fraud implications. Of all the current CMS audit initiatives – RAC audits, MIC audits, etc. – it is vital that providers facing ZPIC audits immediately and effectively address targeted audit issues.
ZPIC zones align with Medicare Administrative Contractor (MAC) jurisdictions and there are seven Zone Program Integrity Contractor regions:
Zone 1: SafeGuard Services
California, Hawaii, and Nevada.
Zone 2: AdvanceMed
Alaska, Arizona, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming.
Zone 3: Cahaba
Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, and Wisconsin.
Zone 4: Health Integrity
Colorado, Oklahoma, New Mexico and Texas.
Zone 5: AdvanceMed
Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia.
Zone 6: [Not Yet Awarded]
Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Washington DC
Zone 7: SafeGuard Services
Florida and Puerto Rico.
The inevitable next step… CMS is developing a Unified Program Integrity Contractor (UPIC) strategy that restructures and consolidates the current Medicare and Medicaid integrity audit programs. Ultimately, this strategy appears to be designed to reduce the vast decentralization of program integrity initiatives and move forward with a more centralized structure.
The Center for Program Integrity (CPI), as part of CMS, is implementing a wide range of strategies that CMS believes to be designed to reduce fraud, waste, abuse and other overpayments. The concept of a unified program integrity strategy involves contractors performing work across the Medicare and Medicaid program integrity continuum. The program incorporates data matching, coordination, and information sharing to identify fraud or abuse that may have “slipped through the cracks” of CMS’ other ongoing initiatives.
According to CMS, this unified program integrity strategy is designed to build upon the improvements that CPI has made over the past several years in multiple arenas. CMS also anticipates that this approach will lay the groundwork for fostering further program integrity coordination with other private and governmental payers across the entire health care industry:
(1) Break down the boundaries between Medicare and Medicaid program integrity activities to create a truly holistic and coordinated Medicare/Medicaid program integrity strategy;
(2) Create a more unified, coordinated nationwide program integrity strategic framework enabling the CMS to set national goals and priorities (after consultation with the Contractors) to ensure that local or regional program integrity activities are consistent with the CPI’s national-level strategy, while still allowing for some regional variation in program integrity activities to respond to local or regional trends in waste, fraud, and abuse;
(3) Further enable cooperation and communication between the various regional program integrity Contractors to ensure a truly national approach to providers or trends that cut across regions;
(4) Strengthen the CMS’s national-level direction of the Contractors’ work by ensuring a rapid, accurate flow of information to the CMS about all levels of the contractors’ workload and activities; and
(5) Ensure that the CPI’s new and emerging centralized fraud detection mechanisms and other tools, for example the Fraud Prevention System predictive analytics tool (“FPS”) and the Health Care Fraud Prevention Partnership (“HFPP”), are fully and consistently leveraged across the entire nation.
Providers work hard and deserve payment for insuring exceptional care and services to Medicare beneficiaries. Yes, there are rules, but the system of rule-making and implementation is extraordinarily dynamic. The Centers for Medicare and Medicaid Services (CMS) has 10,000s of employees and contractors assisting in changing and enforcing the rules, it is simply impossible for a single provider to keep pace.
Jackson Davis HealthCare is the nation's leading resource for Medicare audit defense and Medicare appeals. Over the past 27 years, we have assisted the nation's leading providers in defending 10,000s of overpayment challenges, winning Medicare appeals cases and performing vital due diligence for acquisitions. Our staff are experts in building appeals and defense cases for a full range of RAC audits, ZPIC audits, MAC audits, OIG audits and USAO audits.