Health Integrity LLC, the zone four (Colorado, New Mexico, Oklahoma, and Texas) Zone Program Integrity Contractor (ZPIC), has begun requesting medical records for review.
The ZPICs are Medicare audit contractors that specifically identify cases of fraud and abuse. According to the CMS Program Integrity Manual, ZPICs may "take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped."
During HCPro's November 3 audio conference, Zone Program Integrity Contractors Learn Who They Are, What They Want, and How to Respond to a Review, a caller from Oklahoma shared that a Health Integrity representative visited the facility recently and stayed for a two-day, on-site audit. During the visit, the auditor reviewed more than 40 medical records related to one-day stays dating back as far as 2007.
This information came as a mild surprise to Robert Wade, partner at Baker and Daniels, LLP, in South Bend, IN. Wade said ZPICs have the authority to start reviews as soon as they are awarded the contract, and Health Integrity was awarded the zone four contract in February.
Facilities should be aware that ZPICs could notify the facility via fax a mere hour before the visit. This can leave little time for the facility to prepare. Wade said in situations where ZPICs give short notice, facilities are within their rights to supplement any requested records with supporting documentation even after the visit is complete.
So far CMS has awarded only three of the seven ZPIC contracts:
- Zone 4: Colorado, New Mexico, Oklahoma, and Texas—Health Integrity LLC
- Zone 5: Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia—Advance Med
- Zone 7: Florida, Puerto Rico, and Virgin Islands—SafeGuard Services LLC
So what does this information mean for providers that are within one of these zones?
"They can come knocking at any time," Wade said.
Consequences of a ZPIC review include payment denials, recoupment of overpayments, and referral to other law enforcement agencies. Because ZPICs can refer cases to the Department of Justice, Office of Inspector General, or other law enforcement agencies, a ZPIC review may only be the first step in a long legal battle.