Jackson Davis HealthCare (formerly the Castle Rock Medical Group) professionals have assisted hospitals, physicians, SNFs, physical therapists and DME suppliers facing extensive and far reaching Zone Program Integrity Contractor (ZPIC) audits.  Our industry-leading compliance and legal services staff have extensive experience in working with providers facing pre-payment reviews and select claim denials associated with a wide range of CMS program integrity audits.

We have worked closely with providers to achieve enhanced outcomes associated with Program Safeguard Contractor and Zone Program Integrity Contractor audits including experience with - Health Integrity, CSC AdvanceMed, Western Integrity Center, Cahaba GBA & SafeGuard Services.

To date, our industry-leading clinical, compliance and legal professionals have worked with providers facing extrapolated ZPIC (or PSC) repayments ranging between $48,000 to $2.1M.  Specifically, we have assisted providers with evaluating ZPIC medical review and coding outcomes, ZPIC audit extrapolation, the filing of ZPIC appeals (or PSC appeals) and the mitigation of potential CMS fraud implications.

Zone Program Integrity Contractors (ZPIC Audits / PSC Audits)

While the Medicare Recovery Audits (RAC Audits) program continues to focus the majority of efforts toward hospital adoption of CMS evidence-based coverage policies and site-of-service issues, CMS has launched another major initiative to directly challenge providers.  Although the program - Medicare Zone Program Integrity Contractors (ZPIC) - was not officially rolled out with an emphasis on physicians, SNF, DME suppliers and physical therapy billing, that is exactly where the program has been recently focusing efforts.

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 evidence-based policy auditing activities.  While ZPIC audits are similar in many ways to other CMS 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 PSC audits or ZPIC audits immediately and effectively address targeted audit issues. 

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Medicare Audits & Medicare Appeals Education - $59 Webcasts

Join our industry-leading clinical auditors, compliance professionals and legal staff for the nation's best Medicare audits and Medicare appeals webcasts!

April 27, 2010 - 2:00pm - 3:00pm EST
CMS Payment Criteria - Automated RAC Audit Focus Areas

This presentation will address all the major, automated RAC audit focus areas and their related CMS payment criteria (hospital / physician / physical medicine only - no DME session today).  Specific focus areas include Blood Transfusions, Untimed Codes (Physical Therapy initial and re-evaluation codes), IV Hydration Therapy, Bronchoscopy, once in a lifetime procedures and a handful of other major automated focus areas.  This discussion will include all major areas for each of the 4 regions.

Please send your registration request and contact information to us via e-mail at support@zpicaudits.com.  Registrations must be received no later than April 26.  You will receive an e-mail confirmation with sign-on information and password prior to April 27.  The cost is $59 per healthcare provider, health plan, health law attorney, consulting organization or Medicare beneficary.

May 4, 2010 - 2:00pm - 3:00pm EST
Inpatient Rehabilitation Facility - NEW 2010 CMS Payment Criteria

Detailed discussion of new 2010 IRF Regulations - This presentation will address CMS payment criteria for Inpatient Rehabilitation Facility admissions.  RAC audits recouped almost $60m in perceived overpayments from California IRF providers and we will discuss the CMS "not so vague" concepts of IRF medical necessity, preadmission screening criteria and required clinical documentation.

Please send your registration request and contact information to us via e-mail at support@zpicaudits.com.  Registrations must be received no later than May 3.  You will receive an e-mail confirmation with sign-on information and password prior to May 4.  The cost is $59 per healthcare provider, health plan, health law attorney, consulting organization or Medicare beneficary.

May 11, 2010 - 2:00pm - 3:00pm EST
Percutaneous Coronary Intervention (PCI) & ICD Surgical Procedures - Inpatient or Outpatient?

This presentation will address one of the primary CMS audit focus areas and specifically considers CMS challenges to performing these surgical procedures in the "wrong setting".  Critical issues such as the CMS Inpatient Only list, inpatient admitting criteria, documentation requirements and case management will all be discussed in detail.  This will be a great discussion for Case Management, HIM and financial staff.

Please send your registration request and contact information to us via e-mail at support@zpicaudits.com.  Registrations must be received no later than May 10.  You will receive an e-mail confirmation with sign-on information and password prior to May 11.  The cost is $59 per healthcare provider, health plan, health law attorney, consulting organization or Medicare beneficary.

ZPIC Audits / PSC Audits - Primary CMS Focus Areas

Prior to the 1996 enactment of the Health Insurance Portability and Accountability Act (HIPAA), Medicare program safeguard activities were funded from the contracted fiscal intermediary’s general program management budget.  However, HIPAA revised the Social Security Act and established the Medicare Integrity Program - accelerating today’s focus on Medicare fraud, abuse and enforcement of CMS evidence-based coverage policies.

The Medicare Integrity Program’s (MIP) primary purpose is to deter fraud and abuse in the Medicare program by giving CMS authority to enter into contracts with outside entities and insure the “integrity” of the Medicare program.  In 1999, the Centers for Medicare & Medicaid Services (CMS) developed the PSC program to support the MIP, stop Medicare fraud and facilitate provider adherence to codified CMS Payment Criteria, Conditions of Participation and applicable judicial rulings.

ZPICs (formerly known as PSCs) have a contracted Statement of Work (SOW) that encompasses all of the fundamental activities required for CMS program safeguard activities.  Basically, a PSC (or now referred to as a Zone Program Integrity Contractor – ZPIC) is generally responsible for one or more of the following CMS audit focus areas - (1) pre or post pay medical review of claims, (2) data analysis, (3) benefit integrity and/or fraud detection, (4) cost report audits and (5) provider education.

At the highest level, CMS considers an individual ZPIC (or PSC) as being responsible for detecting, deterring and even preventing Medicare fraud and abuse.  In this capacity, the ZPIC is directly responsible for operating areas such as investigation, case development, administrative solutions and referral to law enforcement. 

With the establishment of ZPICs, fiscal intermediaries and Medicare administrative contractors typically have some or all of their program safeguard duties removed from the scope of their responsibility.  Step-by-step, CMS appears to be developing a more concentrated functional contracting focus for specific areas such are benefit integrity and claims processing activities.

ZPIC Audits / PSC Audits - CMS Medical Review Process

The CMS Medical Review (MR) program is designed to promote a structured approach in the interpretation and implementation of Medicare policy. The ultimate goal of the MR program is to identify and reduce Medicare program vulnerabilities (areas of potential Medicare fraud or abuse) relating to coverage and by taking the necessary action to prevent or address these areas.

The CMS’ national objectives and goals as they relate to medical review are as follows: 1) Increase the effectiveness of medical review payment safeguard activities; 2) Exercise accurate and defensible decision making on medical review of claims; and 3) Collaborate with other internal components and external entities to ensure correct claims payment, and to address situations of Medicare fraud, waste, and abuse.

In order to identify and challenge perceived Medicare fraud & abuse issues, PSC and ZPIC audits are based upon a combination of claims data from multiple sources (fiscal intermediary, regional home health intermediary, carrier, and durable medical equipment regional carrier data).  By combining data that originates from a full range of CMS contractors, the Medicare PSC / ZPIC contractor creates a complete profile of the beneficiary’s claim history regardless of where the claim was processed.

Although Quality Improvement Organizations (QIOs) continue to perform reviews related to quality of care and expedited determinations, they no longer perform the majority of utilization reviews for acute PPS hospitals or LTCH claims. The review of acute PPS hospitals and LTCH claims is now the responsibility of other CMS program contractors including: Carriers, Fiscal Intermediaries (FIs), Program Safeguard Contractors (PSCs), Zone Program Integrity Contractors (ZPICs) and Medicare Administrative Contractors (MACs).

While not all contractors perform all Medical Review functions, MR functions may include: analyze data, write local coverage determinations (LCD), review claims and educate providers.  Specific efforts may include: