CMS (Centers for Medicare and Medicaid) has been combatting the issues of fraud, waste and abuse (FWA) for decades. Different integrity programs have been put into effect over the years. In 1999 CMS implemented Program Safeguard Contractors (PSCs) to support the Medicare Integrity Program (MIP). PSCs are now transitioning to ZPICs (Zone Program Integrity Contractors). These contractors are tasked with identifying fraud, waste and abuse across all Medicare claims via Safeguard audits.
ZPICs certainly have quite a lot of power, and they can wreak havoc on all types of providers, from physicians and physical therapists to home health agencies (HHAs). Any type of audit request is a reason for concern. However, a Safeguard audit conducted by a ZPIC is one of the most serious audit requests in the health care field today, and should be addressed promptly and comprehensively in order to avoid further investigations or even worse, suspension of payments.
Wielding Their Power
Once a ZPIC is assigned a case due to a question of benefit integrity, he/she has access to the CMS National Claims History data, which provides a complete overview of a patient’s treatment no matter where the claims were processed over the years. In addition to this access, below are just a few of the investigative methods they can conduct unless law enforcement disagrees:
- Review a small sample of claims submitted within recent months. Depending upon the type of issue, the ZPIC may request medical documentation or other evidence relevant to the validity of the claim.
- Interview by telephone a small number of beneficiaries. However, if this conversation is not handled correctly it can be particularly alarming to patients.
- Look for examples of previous contacts by another Medicare contractor regarding similar violations, including education/warning letters or contact reports containing similar or related complaints.
- Review telephone calls or written questionnaires to physicians confirming the need for home health services.
- Analyze local patterns or trends of practice and billing against national and regional trends.
The purpose of a Safeguard audit is to determine if FWA really exists or if it is simply the result of billing errors. If it appears to be just a billing error, then the ZPIC will ensure inappropriate claims will no longer be paid and any overpayments will be returned. However, if a case of fraud is suspected then it will be referred to the Office of the Inspector General (OIG) to determine if initial criminal or civil prosecution is warranted. Payments may be suspended, which can result in grave consequences and sometimes even unrecoverable harm to a home health agency (HHA). Many HHAs have even closed their doors for this very reason.
There is Help
The first step to preventing a Safeguard audit is to ensure your team is educated and knowledgeable about possible areas that may trigger one. Our team of experts at 5 Star Consultants can help you to stay in compliance about the latest documentation regulations by assisting you with QAPI and clinical record reviews. In addition, we offer onsite or virtual training for your staff on OASIS, continued survey readiness, coding, Medicare regulations and much more.
Do not let the thought of a Safeguard audit keep you up at night. Contact 5 Star Consultants today at [email protected] or (866) 428-4040 to ensure your staff is knowledgeable and in compliance.
Source: “ZPICs – The Most Dangerous Weapon in Medicare’s Arsenal” by Denise Fletcher, National Registry of Rehabilitation Technology Suppliers Website