[jgist]

Just wondering if anyone else has experienced ZPIC audits! If you have not "get ready" There are three providers in our area that have essentially had there business shut down because of these audits. Two of the businesses have had over 300 requests and one had 600. You have 30 days to respond and 5 to 8 of those days has been time spent in the mail. They are auditing EVERYTHING that was submitted for a month, shutting down cash flow. Let me give you an example of some of the stuff requested. For a replacement battery charger on a pwc that was purchased in '08. They want to provide "chart notes from 11-08 to current discussing DX Osteoarthritis of leg, Arthropathy, CHF, Rotator cuff syndrome to support power mobility usage." This is for a chair already purchased. I have been in this business 22 years, I am all for eliminating the Fraud and Abuse, but I have never seen anything like this and I am just about ready to exit the business and I guess that's what they want!

[AndreaStark]

I have seen several articles regarding the increase in audits from both CERT, RAC and ZPIC contractors. Here is what DME Consultant Andrea Stark had to say about the audits in a recent interview published by Homecare Magazine: (The full story is at http://homecaremag.com/operations/zp....html?smte=wl)

Auditing of HME claims is definitely on the upswing, confirmed consultant Andrea Stark of MiraVista LLC, Columbia, S.C.

"It seems like all of the new contracts CMS is awarding have to do with benefit integrity," she said. "You've got your ZPICs, CERTs, RACs, jurisdiction medical review departments and the OIG."

All of them-the ZPIC, the Comprehensive Error Rate Testing contractor, the Recovery Audit Contractors, the medical review departments of the DME MACs and the Office of Inspector General-have authority to conduct audits of HME providers.

"CMS has been under pressure to be held accountable [for the integrity of the Medicare trust fund]," said Stark. "And when the rocks start rolling down the hill, they start taking out a lot of things. So they certainly have increased the number of contractors. There are more avenues for detection of fraud in the program."

The RAC and the CERT only look at claims that have been paid, and the CERT is seeking to catch contractor errors, Stark noted. While the RAC has been doing only automated reviews, she said the types of audits it will be doing "are going to get increasingly complex."

The ZPICs and the medical review departments audit live claims in an effort to ferret out fraud, Stark said, and they do both post- and pre-pay reviews. They also handle external fraud referrals. "They are doing data analysis of claims and trying to anticipate trends and spikes and billing aberrations," she explained.

Putting providers on prepayment review, as has been done in Texas, is within the ZPIC's authority, she said. "Usually, there are extenuating circumstances, but they do have flexibility in their contract."

That said, Stark agrees that audit contractors are not always in the right. In one example, she said, "there has been an issue with oxygen claims.

"CERT contractors have taken some liberties with interpreting Medicare guidelines regarding medical necessity," she said. "They not only want to see the documentation normally in the patient's file but also documentation of a current visit within the last six months. Patients, under the [local coverage determination], are not required to go back to their physician. CERT has been denying payment if that visit is not done. That's not anywhere in the policy, and it is a source of contention. Many of these claims do end up being reversed."

Not Documented = Not Done
To deal with the audits, Stark said, "providers need to anticipate and they need to prepare. These should not be massive surprises to providers. It is usually public knowledge [that an audit is being conducted on a particular product] ... We are talking power mobility, diabetic supplies, CPAP supplies-a lot of them have been on the list for quite a while now."

To get a sense of what is on the horizon, she suggested that providers take a look at the OIG work plan for 2010. The "hot audit" items, she said, include use of the KX modifier, billing after the date of death, power mobility, hospital beds, oxygen, enteral nutrition, diabetic supplies, repairs and service. (For more, see DME Makes OIG Work Plan Once Again, Oct. 5, 2009.)

Sincerely,

Michelle Hamel Duncan
Communications Specialist
MiraVista, LLC
PO Box 11544
Columbia, SC 29211
Phone: 803.462.9959 ext.252
Fax: 803.758.2450
michelle@miravistallc.com
www.miravistallc.com

For outsourced DME billing, try ClaraVista, LLC.
www.claravistallc.com/billing.php
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[Regina]

I just wanted to point out that my sister, who works for Social Security, has several former co-workers who are now at CMS, and tell her that it is an unholy mess. This doesn't help us now, but hopefully CMS will implode sometime in the future.