ZPIC Audit Defense | ZPIC Appeals | Mock Medicare Audits

Jackson Davis HealthCare
Medicare Audit Defense,
Medicare Appeals & ZPIC Shadow Audits
Contact us at (303) 586-5003
support@jdhcare.com

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The Healthcare Provider's #1 Medicare Audit Defense & Medicare Appeals Team
ZPIC Audit Defense - ZPIC Appeals - Medicare Shadow Audits

Medicare ZPIC Appeals / ZPIC Shadow Audits

Call us today for a free consultation at (303) 586-5003. Hospital appeals - Physician appeals - SNF appeals - Home Health appeals - Hospice appeals - Physical Therapy appeals - DME appeals. Jackson Davis is in your corner!

Jackson Davis HealthCare is the nation's #1 resource for Medicare audit defense and Medicare appeals. We have assisted providers and Medicare attorneys nationwide in evaluating 1,000s of overpayment issues and winning close to 90% of all Medicare appeals. So, what's the secret and why should you choose to work with Jackson Davis? Experience - Knowledge - Integrity - Dedication - Passion - Success.... no secret, just a belief that providers work hard and deserve payment for insuring exceptional care and services to Medicare beneficiaries.

Over the past 25 years, Jackson Davis HealthCare professionals have assisted providers and attorneys nationwide in defending 1,000s of Medicare overpayment issues. As your unwavering advocate, Jackson Davis leads the nation in building winning Medicare appeals cases. Jackson Davis is the undisputed leader in understanding and synthesizing Medicare rules, regulations and guidance - no one understands Medicare coverage criteria better than we do - and we prove it everyday.

Yes, there are rules, but the system of rule-making and implementation is extraordinarily dynamic. The federal government 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. Call Jackson Davis today - we can help and we are in your corner to stay!

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Turning the Page - The Winning ZPIC Appeals Strategy

With the Medicare ZPIC audit program being in full force nationwide, providers are preparing for ZPIC audit denials and setting in motion a series of processes to successfully address ZPIC appeals. Hospitals, physicians, SNFs, home health agencies, hospices, physical therapists, DME suppliers and a full range of other healthcare providers are quickly and aggressively turning their focus to fighting & winning ZPIC appeals. Defending Medicare or Medicaid auditor denials, avoiding potential Medicare fraud allegations and holding on to hard earned cash reserves are all critical.

Based upon our work with providers facing Medicare audits (ZPIC audits, RAC audits, etc.) and potential Medicare fraud implications, the 5 most frequently asked questions are (1) how do we keep our money, (2) how do we stop Medicare audits and denials in the future, (3) how do we win current ZPIC appeals, (4) how do we beat a zpic extrapolation, and (5) how do we stop Medicare audit outcomes from turning into Medicare fraud allegations.

We simply can't emphasize enough the challenges to winning ZPIC appeals and the very real possibility of ZPIC audit outcomes becoming potential Medicare fraud issues. Here are a handful of things to consider when tackling Medicare ZPIC appeals:

1) Medicare Coverage Criteria will give you the winning hand

Several U.S. courts have held that a provider's adherence to Medicare coverage criteria trumps all in the evaluation of claim denials. In fact, the courts have held that - when Medicare coverage criteria exists for a given focus area - CMS MUST use the payment criteria when evaluating claims for payment.

Over and over again we are seeing CMS contractors not following the rules and applying their "opinions" when denying cases. Jackson Davis takes these contractors head-on and builds your case one block at a time - always based upon Medicare coverage criteria.

2) Develop Medicare Coverage Criteria Case Summaries for all "winnable" ZPIC appeals

Nothing speaks louder in the Medicare appeals process than providers that painstakingly tie Medicare coverage criteria to medical records documentation and present an evidence-based argument for payment. On the other hand, using the "appeal everything" strategy and not making internal operational changes to adhere to Medicare coverage criteria is a guaranteed approach to facilitating potential Medicare or Medicaid fraud investigations.

3) Submit all required documentation during the first 2 stages of the ZPIC appeals process

It is critical that you file all the supporting documentation relating to a given case no later than Stage II - Reconsideration. After this stage, it is extremely difficult to add supporting documentation to a case under appeal. When completing ZPIC appeals and "mock Medicare audits" with providers across-the-country, we have found a number of hybrid medical record structures and significant challenges to submitting medical record documentation for review.

4) Focus on adhering to Medicare Coverage Criteria and winning your ZPIC appeals

Remember, the Medicare Appeals Council is the last administrative step in the Medicare appeals process. The Medicare Appeals Council relies heavily on Medicare coverage criteria in making decisions and their approach has shown time-and-time again that "legal or procedural" arguments are extremely difficult to win.

5) The best odds of beating a ZPIC extrapolation? Focus on winning the sample cases...

Most (but not all) ZPIC extrapolations are built on Medicare statistical methodologies. Can an extrapolation be defeated using legal challenges to the statistical methodology? Yes. However, the much, much more reliable approach is to win the underlying cases represented in the sample and thus destroying the integrity of the sampling and extrapolation.

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Medicare Appeals - Denials & Overpayment Determination

Jackson Davis works directly with providers and partners with leading Medicare law firms to build winning Medicare appeals cases and reduce the anxiety of potential Medicare fraud allegations. The following information MUST be included with your request for all Medicare Appeals - RAC appeals, ZPIC appeals, DOJ appeals, MAC appeals, MIC appeals or individual Medicare beneficiary appeals.

            Beneficiary name
            Medicare Health Insurance Claim (HIC) Number
            Specific service(s) and/or item(s) for which the redetermination / reconsideration is being requested
            Specific date(s) of the service; and
            Name and signature of the provider or the representative of the provider

First Level – Redetermination (Medicare Administrative Contractor) - Claim denials or overpayments must be initially reviewed (appealed) to the appropriate Medicare Administrative Contractor (MAC) by requesting a redetermination of the claim within 120 days of the Medicare's initial decision. Medicare Administrative Contractors are required to respond to a provider’s request for redetermination within 60 days of receipt.

Second Level – Reconsideration (Qualified Independent Contractor) - If a provider is dissatisfied with the outcome of the Level 1 appeal or redetermination process, a request for “reconsideration” may be filed with the appropriate Qualified Independent Contractor (QIC) within 180 days of the redetermination. Requests for reconsideration are required to be processed within 60 days by the QIC.

Third Level – Administrative Law Judge Hearing - If a provider is not satisfied with Level 2 and the result of reconsideration, a hearing before an Administrative Law Judge (ALJ) can be requested. The amount in controversy must be a minimum of $120 and requests for a hearing from an ALJ must be received within 60 days of the provider’s notice of the reconsideration outcome.

Fourth Level – Medicare Appeals Council (MAC) - If the Level 3 appeal and decision by the ALJ is considered unfavorable by the provider, a fourth level appeal request may be filed with the Departmental Appeals Board (DAB) / Medicare Appeals Council (MAC). Requests for a MAC review must be filed within 60 days of receipt of the ALJ’s decision. The MAC must subsequently issue a determination within 90 days of the review.

Fifth Level – U.S. District Court Review - If the Level 4 decision of the MAC is deemed unfavorable to the provider, the final step in the appeals process is to file suit in U.S. District Court. Requests must be filed within 60 days of the MACs decision and the amount in controversy must be at least $1,180.

CMS Transmittal 141 - Limitation on the Recoupment of Medicare Audit Overpayment Determinations

CMS Transmittal 141 specifically addresses a diverse range of Medicare appeals issues and discusses revisions to the Medicare appeals process. Probably the most important aspect of Transmittal 141 is the timing of recoupment by CMS for overpayment determinations by contracted recovery auditors.In summary, time frames relating to the filing of appeals during the first 2 steps of the Medicare appeals process have not changed (i.e. 120 days to file for redetermination and 180 days to file for reconsideration). However, in order to stop the automated recoupment of overpayments, providers MUST file Medicare appeals within 30 days for redetermination and within 60 days for reconsideration.