Expect audits to get more aggressive

Friday, January 27, 2017

atlanta – When ZPIC auditors come calling, it’s important not to throw up your hands in surrender because there’s too much at stake, said healthcare attorney Ross Burris.

“They can suspend your payments; they can revoke your status,” said Burris, a shareholder with Polsinelli. “That six-month revocation can turn into 12 months. You’ll be shocked at the aggressive nature and authority of some of these contractors.”

ZPIC audits are typically provider specific and contractors will hit you with multiple requests for information. Under prepay review? You could find them looking at your previous payments, as well.

“Contractors have an image in their heads and you need to change that image,” said Wayne van Halem, president of The van Halem Group. “You’re not committing fraud.”

Contractors perform two types of audits: reactive, which are the result of allegations of fraudulent practices; and proactive, which account for 95% of claims and are based on data analysis.

“We saw bid winners put on 100% prepay review during the first round of competitive bidding because data analysis showed a spike in billing,” said van Halem. 

Once the ZPIC contractors decide to audit you, their first step is often to interview patients to see if they know the referring physician and whether they are using the equipment.

“As a lawyer I find it incredible that, two years after the fact, they can (rely on beneficiaries’ memories),” said Burris. “On appeal, you might point that out to the ALJ.”

Ultimately, the seven ZPIC zones will transition to five UPIC zones. With a potential 10-year, $2.5 billion contract at stake, expect things to heat up as contractors jockey for a piece of the audit pie, says van Halem.

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       It might be time to start letting medicare patients know that they can not leave the hospital with oxygen unless they are in a chronic stable state. Meaning, a diagnosis of pneumonia and hypoxemia does NOT qualify for oxygen.

     I don't see hospitals keeping patients because they can not be weaned off oxygen. I don't see providers willing to provide oxygen for free either.

    We are getting to a critical point where patients will be losing their lives due to overregulation. The funny part is that CMS wont allow them to pay cash for it either.

    I would love to see a headline that reads, "Cable bills cost more per month than Life sustaining equipment".