In February 2004, Mr. Benvenuti was appointed Inspector General for the Cabinet for Health and Family Services where he served until January of 2007.  Among other things, the Office of Inspector General is charged with investigating and detecting fraud, waste, and abuse in the Medicaid program, as well as allegations of prescription drug abuse and diversion.  Prior to his appointment as Inspector General, Mr. Benvenuti was an attorney with Stites & Harbison, PLLC.
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ZPIC Appeals & Legal Support Services Profile

Jackson Davis HealthCare provides the nation's leading solution for the submission of Medicare appeals.  Jackson Davis industry-leading Medicare advisors and clinical documentation auditors work directly with the nation's best health law firms and provide an unmatched compliance and legal services solution.

See the Medicare ZPIC Appeals section for a detailed overview of the Jackson Davis HealthCare ZPIC appeals support process:

           Step 1 - CMS Criteria-Based Case Review
           Step 2 - Prepare ZPIC Appeals & Criteria-Based Case Summary
           Step 3 - Submit ZPIC Appeals for Redetermination
           Step 4 - Submit ZPIC Appeals for Reconsideration
           Step 5 - Support ALJ Hearing - Provide Regulatory & Clinical Expert Testimony

Turning the Page - A Winning ZPIC Appeals Strategy

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

Based upon our work with providers facing Medicare audits (ZPIC audits, RAC audits, etc.), the 4 most frequently asked questions are (1) how do we keep our money and not pay a ZPIC's extrapolated amount, (2) how do we stop ZPIC audit denials in the future, (2) how do we win current ZPIC appeals, and (3) how do we stop ZPIC audit outcomes from turning into 'fraud' allegations.

Within the ZPIC Appeals section we address a wide range of issues and strategies to consider when initiating the ZPIC appeals process.  Most importantly, however, 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 ZPIC appeals:

1)  CMS Payment Criteria will give you the winning hand

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

2)  Develop CMS Criteria-Based Case Summaries for all "winnable" ZPIC appeals

Nothing speaks louder in the Medicare or Medicaid appeals process than providers that painstakingly tie CMS Payment 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 CMS payment 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 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 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 CMS Payment Criteria and winning your appeals

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

CMS / Medicare ZPIC Appeals Resources

The ZPIC appeals process mirrors other Medicare appeals, but the presence of extrapolated outcomes - as well as Medicare fraud implications - can make ZPIC appeals somewhat more challenging.  Please see the ZPIC Appeals section for further information and guidance relating to recommended appeals work plan components.  The following are CMS ZPIC appeals documents highlighted on the cms.hhs.gov website:

                        ZPIC Appeals - The Medicare Appeals Brochure
                        ZPIC Appeals - Appeals Process Diagram
                        ZPIC Appeals - Limitation on Recoupment
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Recommended ZPIC Appeals Law Firms

The ZPIC appeals process can be extremely costly and the timeliness of CMS recoupment is a major challenge.  In addition, the ever-present issues relating to Medicare fraud can be very serious.

Knowledgeable, independent health law firms and internal legal counsel representatives play vital roles in the completion of proactive ZPIC medical review assessments & the submission of ZPIC audit appeals.  In addition, Jackson Davis clinical documentation auditors, Medicare billing compliance professionals and legal support staff emphasize a multi-disciplinary approach to addressing CMS appeals.  We can assist in providing a full range of ZPIC audit support and ZPIC appeals submission efforts as well as providing expert testimony, clarifying regulatory requirements and contributing to extensive research efforts.

Jackson Davis HealthCare (formerly the Castle Rock Medical Group) has researched hundreds of health law firms nationwide and we maintian working relationships with only the very best.  Our recommended health law firms and attorneys have hundreds of years of experience, they have assisted with over 10,000 Medicare appeals, ZPIC appeals and highly sensitive Medicare fraud related issues.  This very select group of attorneys and firms that can bring both a breadth of experience with the Medicare appeals process and a depth of ZPIC audit appeals knowledge to each client - without the additional cost.

Please contact us directly for questions regarding CMS efforts to stop Medicare fraud & abuse, Medicare audits, Medicare appeals, CMS auditing tools, CMS reference documentation, CMS PI Warehouse, ZPIC appeals or PSC/ZPIC audits by Health Integrity, CSC AdvanceMed, Western Integrity Center, Cahaba GBA & SafeGuard Services at (303) 586-5003 or support@zpicaudits.com.