Medicare and ZPIC Audits Are Coming!

Last month the ICS sent out an E-News about Medicare audits being on the rise. In addition to Wisconsin Physicians Service (WPS) increasing their audits, the Zone Program Integrity Contractors (ZPICS) are also increasing audits. The ACA also announced earlier this month that ZPIC contractors are sending out self-audit requests. If you are a participating or a Non-participating provider for Medicare, it is very important to take this news seriously and make sure that your office staff is aware of this information. If your office receives a records request or a self-audit request, you need to respond. Make sure that your staff knows that any correspondence from Medicare, CERT, or Cahaba (the ZPIC auditor for Illinois) is brought to your attention immediately so you can respond in the time frame requested.

This article is not meant to cause undue alarm or cause panic, but it is to inform you that the government and Medicare are serious in their efforts to reduce healthcare fraud, waste, and abuse. I have talked to doctors and staff who are not concerned with being audited, and many chiropractors believe that they do not see enough Medicare patients to be audited. However, having a low Medicare patient volume does not keep a provider from being audited. I have also talked to several non-par providers who believed that they could not be audited; this is not the case. You can be audited if you are a non-participating physician with Medicare. Understanding who is monitoring your claims, who can ask for your records, and what they are looking for is more important than ever.

Advertisement

The use of high tech fraud detection devices help all third-party payers track a doctor’s coding and billing practices. Third-party payers have very sophisticated computer programs that can profile your billing patterns including: which diagnosis and CPT codes you use, how often you use these codes, and the number of times you see a patient. Insurance carriers use the data they receive to determine if your care is medically necessary, as well as correlate a patient’s current treatment history with the patient’s past treatment history. They not only analyze your data, but they compare your billing information to your peers in your region, state and nationally; and they may even compare your data with other types of providers. Third-party payers can track any information that they want, and each payer may be tracking different information. Blue Cross might be looking at the number of orthotics a doctor is billing, and Medicare might be looking at the average number of visits doctor bills per beneficiary in a six month period.

Medicare Administrative Contractors (MACs) are contractually obligated to perform medical reviews and audits. In Illinois the Medicare A and B MAC is WPS. MACs perform Medical Reviews (MRs). Many MRs are automated, and the provider doesn’t even know that they are under review. Third parties use sophisticated data analysis to examine claims. When an atypical billing pattern is identified or other claim form problems arise, records may be requested.

MACs perform two types of post-payment reviews. The first type of review occurs when a provider-specific problem is found. In this case, the reviewer will request 20-40 files from the provider. The second type of post-payment review occurs when a widespread problem is identified such as a jump in billing for a certain CPT code by several providers. In this case the reviewer will ask for patient files from multiple providers. When a probe review determines that a problem exists, it is classified a minor, moderate or significant (usually based on the number of claims paid in error), and the appropriate corrective action is taken by the MAC. WPS uses statistical analysis to determine a chiropractor’s use of CPT codes 98940-98942 and then compares those results to the results of our peers. When corrective action is needed the MAC may educate the provider of the appropriate billing and documentation procedures, or conduct pre-payments reviews and/or post-payment reviews. A pre-payment MR is when a percentage of a providers claims go through a review process before any payment is made to the provider. A post-payment MR is when multiple claims are reviewed after payment has been made. From the reviewed claims an error rate will be determined, and then the MAC will extrapolate an overpayment amount using results from the audit. If a provider is under a pre-payment or post-payment review, you may need help from a professional trained in medical compliance. Once the problem(s) are corrected the provider will no longer be on review status. However, if the problems persist, the provider can be excluded from participating in Medicare. Zone Program Integrity Contractors (ZPICs) are responsible for detecting and deterring fraud. ZPICs will be responsible for ensuring the integrity of all Medicare-related claims under Medicare Part A, B, C and D and match data between Medicare and Medicaid. There are seven ZPIC zones based on MAC jurisdictions. At this time Illinois ZPIC contractor is Cahaba. ZPICs use sophisticated data analysis to identify the frequency a CPT code and/or ICD-9 code is used, billing trends, or any other information that identifies a provider/supplier as an outlier. They can look at a beneficiaries entire claim history, no matter who the provider.

ZPIC audits can also be triggered by patient complaints or referrals from CMS, OIG, MACs, FBI, other contractors, etc. They review claims on a pre-payment and post-payment basis. Claims audited on a post-payment basis can be reviewed for any reason within a year, and with good cause, claims reviews could go back four years. ZPIC audits are rarely announced, and they are not random. If a provider is being audited by ZPIC, they most likely have evidence that fraudulent activity may be occurring. They will request a number of records, and if they find payment errors, they will extrapolate from this error rate a dollar amount the provider will need to refund Medicare. In addition to collecting files, ZPIC may interview beneficiaries who received the services in question and the provider’s staff. In addition to owing money to Medicare, the case could be referred to law enforcement and prosecuted under the False Claims Act for criminal and civil monetary penalties (CMP). The provider could be sanctioned by the OIG from all government-funded healthcare programs and could also go to jail.

As stated in our earlier Enews the request for records from Medicare or ZPIC may come with a CD that has an excel spreadsheet with the following columns:

Column A: Medicare Beneficiary
Column B: Beneficiary DOB
Column C: HICN
Column D: Date of Service
Column E: Diagnosis Code
Column F: Amount Paid
Column G: Document the participating event initiating change in diagnosis and/or new onset of symptoms. Identify objective clinical information which supports the diagnosis.
Column H: Identified Overpayment

If you do get a request for records, do not panic (unless you have poor or no documentation). Just because a reviewer requests your notes does not mean you are doing something wrong. Please notify the ICS immediately upon receiving a ZPIC records request/audit. We are coordinating information with the ACA regarding these audits across the country. Additionally, the following steps can assist you with an audit.

1. Never ignore a request for records. Respond to the request within the time-frame specified. This is usually 30 days from the date on the letter requesting records. You can request more time, if you unable to respond in the time-frame given. If a reviewer does not receive photocopy of the documentation requested in the given time frame, the services will be considered non-documented, and the claim(s) will be denied. This will result in an overpayment determination and can trigger even a larger audit or future audits. If additional documentation is requested, doctors must be willing to provide it if at all possible, otherwise your review will be based on the documentation received. Ignoring a request for records can get you in deeper trouble.
2. Carefully read the request letter. It is important to find out what the reviewer is requesting. If a reviewer is asking for certain dates of service, you will want to send documentation for those dates. If the reviewer is requesting supporting documentation, it is important to include the most recent history, exam, outcome assessment questionnaires, and treatment plan that were documented right before the requested dates of service – and if applicable, right after the dates of service. Also include any relevant diagnostic findings, any discharge notes and any notes explaining a patient’s non-compliance with your treatment plan. All this documentation will tell the reviewer a story about why the patients care was medically necessary. Do not send more or less information than what is requested. If you are asked to fill out a ZPIC spreadsheet, column G states that the auditor wants objective clinical information which supports the patient’s diagnosis.
3. Make sure your documentation is legible and can be understood. If your patient or staff cannot read your note or understand your abbreviations then a reviewer will have the same problem. If this sounds like your documentation, then submit a transcribed copy of your notes along with a photocopy of the original documentation. If you make up your own abbreviations and symbols, make sure a legend is included with your notes. The photocopies that you submit to the reviewer should be good quality. You do not want to make it difficult for the reviewer to understand your notes.
4. Never alter your documentation. I have doctors and their staff members call me after receiving a letter requesting records asking how to prepare their notes. Unfortunately, if you do not have the documentation to show medical necessity for care, it is too late to now. Altering medical records that are incomplete or insufficient is considered to be fraudulent activity. Submitting no records or poorly written records is better than records that are fraudulently altered.
5. Sign all your documentation and records. Medical records must be signed by the practitioner who is responsible for providing, evaluating, or ordering the services rendered. This even applies to providers in solo practices. Make sure your signature follows Medicare guidelines. If there is no signature present on the documentation, the claim will be denied upon review. If a handwritten signature is not legible, it is advisable to include a signature sample when responding to a records request. Claims can be denied due to an illegible signature. If your documentation is not signed properly, make sure you provide an attestation statement verifying who performed the services.
6. Send the requested documentation certified mail with a return receipt. This way you have a record of who signed for your documentation and the date they received your packet to prove that you complied with the request.
7. Notify the Illinois Chiropractic Society. If you receive your audit request, please inform the ICS so we can keep track of the number of audits that are occurring and coordinate information with the ACA. I am also available to answer questions you or your staff may have regarding the audit process. This is the time to get help.
8. Appeal when you disagree with the decision of the reviewer. Never assume that the reviewer who initially reviewed your claim has the final word. An appeal can save you from further reviews and even a lot of money in recoupments. Most refund requests are extrapolated. Never pay without appealing. Additionally, many refunds are negotiable. At times, it may be necessary to hire a Certified Medical Compliance Specialist with a specialty in chiropractic or a healthcare attorney to assist you with your appeal. Remember every time you get a denied claim overturned, you are retaining more of your own money and reducing your and the professions error rate. Never pay what they ask without negotiating first.

Editor’s Note: The ICS has received a copy of a template letter that chiropractic physicians are receiving as a part of these audits. To familiarize you with the letter and its appearance, here is a template.