ZPIC Audits

Is Phlebology Being Targeted?
by AJ Riviezzo, MBA

The new Zone Program Integrity Audits (ZPIC), which have been in the making for several years, have really begun to be conducted over the past three months. The goal of these audits is to detect fraud and abuse in Medicare claims. These audits are being done by sub-contractors on behalf of the Medicare Administrative Contractors (MAC). It also appears that these several sub-contractors are paid only on the ‘found’ dollars. This lends serious concerns regarding their processes and the neutrality of the review.

Further, the rules (like those surrounding the RAC audits) were never formalized by Congress. This is allowing the ZPIC sub-contractors to devise their own rules and regulations regarding the process. These rules are certainly not provider friendly to date. It has also created a significant variance between Zones on how these audits are being conducted. In one area it appears they are being treated much like the RAC audits with thirty charts being reviewed on a retrospective review. In another area, ALL claims are being reviewed with payments being denied prospectively, with virtually no feedback as to the reason why save the standard Medicare denial codes.

Attempts to gain further information have, to date, been difficult. One phlebology provider has basically been told that it is not the ZPIC contractor’s responsibility to ‘educate’ the provider, and yet they are still holding essentially all payments prospectively. Thankfully this provider has a relatively small percentage of Medicare patients as part of their payer mix. For a provider with a large Medicare mix, this is tantamount to a forced closure.

Is phlebology being targeted? The author cannot state that it is. However, two phlebology practices are already in review that we know about. Given the small number of providers in review by these ZPIC contractors and given the even smaller percentage of all providers that perform ablations, it does give one serious pause for concern.

So what is a practice to do proactively? First, we recommend that you re-read your Local Coverage Determinations (LCD) regarding phlebology services for your area. Make sure your patients are meeting the medical necessity requirements outlined in the LCD.
Second, the LCD may also have documentation requirements that are specifically required on each chart or operative note. Please review your documentation against these requirements. You may also want to have an external agency conduct a chart-to-bill, bill-to-chart audit. Yes, you can do these on your own but it is a bit like proof-reading your own work. An outside eye will not overlook ‘assumed’ elements.

What are the next steps should your practice be contacted by ZPIC? The request from ZPIC will be for copies of your charts. We recommend sending, as quickly as possible, the copies requested. Typically they are requesting for a specific date of service. We recommend sending all of the documentation necessary for that specific date (e.g. Diagnostic Ultrasound, History and Physical, Operative Note, any other documentation). If they request records for multiple dates of service, send the same type of packet for each date of service. Do not assume they will copy the Diagnostic Ultrasound and attach it to each date of service. They will not do so. We also suggest that you immediately contact an attorney in your area with some ZPIC or at least RAC audit experience.

Now to the vaguely good news. Once ZPIC has denied your claims (recent experience shows a denial rate of over 95%), you can then appeal these denials through the Medicare system. Medicare has five levels of appeal that can be attempted. These are:

1. Redetermination. This goes through MAC and is basically to keep the claims open for additional appeal processes. On the average 50% of claim denials are overturned at this stage.
2. Reconsideration. These appeals go through a completely different department, usually a Physician panel, for review. These reviewers do not work for Medicare or the ZPIC contractor, and are not paid by the denial. (this is a completely independent review team).
3. Administrative Law Judge Hearing. Established for any outstanding claims over $130.00. This stage allows for a teleconference with a legal entity to discuss the medical necessity of the services, and functions like a peer-to-peer review. There is a high level of success at this stage of appeals.
4. Medicare Appeal Council Review. This is an independent team of professionals tasked with reviewing the decision made by the ALJ panel. Any contested issues found in the ALJ hearing will be reviewed here.
5. District Court. Established for any claims over $1260.00. You may request a review in district court.

The encouraging news is that at the 3rd level of appeal, if a physician’s services may not have exactly met criteria set forth by the MAC, the claims may still be considered for payment if the physician is able to state, in a concrete fashion, as to why the services were necessary and prudent.

In short, these ZPIC audits are looking to be both unpleasant and expensive with few guidelines that are required to be followed. It appears the assumption is that fraud has been committed unless proven otherwise. Review your documentation, medical necessity assumptions, and the Local Coverage Determinations soon.