CMS Issues Proposed Rules About Returning Overpayments

Déjà Vu – RAC Prepayment Reviews Are Back!

I.    Overview:

Late last week, the Centers for Medicare and Medicaid Services (CMS) announced that prepayment reviews by Recovery Audit Contractors (RACs) would begin (again) on or after June 1, 2012.  As we previously discussed, CMS had originally delayed the program amid significant provider concerns about its operation.

II.   Background:

RACs have long served an important role in detecting and recovering both Part A and Part B overpayments since the program began in 2005. Utilizing both automatic review edits and complex medical reviews to identify a multitude of claims errors, RACs have greatly assisted the government in its efforts to protect the integrity of the Medicare Trust Fund.  As you know, RACs are paid on a contingency basis, based on the amount of improper payments (either overpayments or underpayments) each RAC identifies and actual recovers. Despite harsh criticism from the provider community, RACs have been successful in their audit and recovery tasks, prompting the Federal government to expand their authority to review claims.

III.   RAC Prepayment Review Demonstration:

Initially announced on November 15, 2011, CMS’ RAC Prepayment Review Demonstration Project was slated to start in 11 states on January 1, 2012, including Florida, California, Mississippi, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri. Through the project, CMS was hoping to ensure that Medicare claims reimbursed by the government were medically necessary and met coding and billing criteria before such claims were paid. Due, at least in part, to significant concerns from providers and hospitals about the substantial administrative burden such review would cause, CMS announced last month that it was indefinitely delaying the RAC Prepayment Review Demonstration Project. As we noted when CMS first announced this delay, while providers may have considered this postponement a victory, CMS still has numerous other contractors actively performing prepayment review audits each day around the country. At the end of the day, the issue really isn’t whether CMS is going to instruct its contractors to conduct prepayment reviews, it really comes down to whether providers are properly meeting applicable medical necessarily, coverage, documentation, coding and billing requirements.

IV.   Impact of Being Placed on Prepayment Review:

As you may know, there is no prepayment review administrative appeals process. As a result, providers placed on prepayment review have little recourse to reverse the decision, and often remain on review for four to six months (although we have seen reviews lasting up to a year) or until the provider is able to show their Medicare Administrative Contractor (MAC) that the services billed meet medical necessity, coverage and documentation requirements. Importantly, this determination is entirely based on the respective MAC’s subjective view of the propriety of a provider’s claims.

It is important to note that prepayment review audits can prove disastrous for providers and hospitals who mainly treat Medicare beneficiaries. Prepayment review effective delays payment for several months, even assuming that the MAC finds the provider’s claims are payable. Often times, providers must also take many of these claims through the administrative appeals process, adding another one to two years before payment is made (again assuming that an Administrative Law Judge finds the claims payable).

V.   Avoiding Prepayment Review:

With RAC prepayment reviews on their way, providers may consider investing in the time and energy now to make sure their claims meet applicable payment requirements. While there is no “silver bullet” to completely eliminate the risk of prepayment audit, a number of preemptive steps exist to reduce the likelihood of such an occurrence. You should consider conducting a “gap analysis” of your practice, and in so doing, you will learn whether your billed services, and associated documentation, meet medical necessity and coverage requirements. You may also review your utilization rates of certain procedures and compare these rates to those of your local, regional and national peers. In all, you need to identify the regulatory benchmarks applicable to your practice, identify where you fail to meet these benchmarks, consider the manner and method to rectify these deficiencies, and add proper procedures and additional risk areas to your Compliance Plan. Such efforts now can leave you in an excellent position to respond to any billing questions by RACs or other Medicare contractors. While RAC prepayment reviews are just another type of audit in a long list of concerns for providers, don’t underestimate the ability of these RACs to identity errors and deny payment.

VI.   Reading the Tea Leaves:

CMS’ rekindled RAC prepayment review program is slated to begin again on June 1, 2012.  With the reimplementation of this project, CMS moves yet another step away from its “pay-and-chase” model.  Among its many advantages, the prepayment review approach greatly reduces the likelihood that the claims being paid by the government are improper. We believe that the scope of RAC and ZPIC prepayment reviews will continue to grow in the near future and will represent a key component of the government’s fraud prevention efforts in years to come.

Liles Parker attorneys have extensive experience conducting “gap analyses” and conducting compliance reviews for health care providers of all types. In addition, our attorneys are skilled in assisting providers who have been placed on prepayment review or subjected to post-payment audit. For more information, please call us today for a complimentary consultation.  We can be reached at: 1 (800) 475-1906.

The Latest Risk Area for Providers: CMS’ EHR Incentive Program Post-Payment Audits

(January 26, 2012):

1.   Background:

RACs, PSCs, ZPICs, HIPAA Auditors, State MFCUs, MICs, Medicaid RACs, HHS-OIG, DOJ, FBI, and Now. . . Patients?

(January 20, 2012):

I.   Background

CMS Delays RAC Prepayment Demonstration Project . . . For Now.

(January 11, 2011):

Background:

Last month, we discussed a new demonstration project by the Centers for Medicare and Medicaid Services (CMS) to test Recovery Audit Contractors’ (RACs’) ability to conduct prepayment review of Medicare Part A and B claims. RACs have successfully identified a wide variety of Medicare overpayments and have become one of CMS’ most important post-payment audit tools. In light of their continued success, last November, CMS announced that RACs would also now conduct  prepayment audits. An initial RAC Prepayment Demonstration Project was intended to cover many of the same types of prepayment review as those currently conducted by Zone Program Integrity Contractors (ZPICs) around the country.  The RAC Prepayment Demonstration Project was initially slated to be conducted in Florida, California, Mississippi, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri.

Recent Developments:

After CMS announced the RAC Prepayment Demonstration Project, it reportedly received an outpouring of concerns regarding the scope of these prepayment audits.  In consideration of these concerns, yesterday CMS announced that it was indefinitely delaying implementation of the Project, and would give 30 days notice before the RAC Prepayment Demonstration Project was reactivated.

Commentary:

Importantly, CMS’ decision to delay the RAC Prepayment Demonstration Project does not mean that they will not ultimately pursue RAC prepayment reviews in the future. Moreover, it is essential that health care providers keep in mind that other CMS contractors are already placing a wide variety of Part A and Part B providers on prepayment review.  As before, providers should regularly review their activities to ensure that all regulatory and statutory requirements are being met.  Broken down into areas of concern, providers should examine:

(1) Were the services administered medically necessary?

(2) Do the services meet Medicare’s coverage requirements?

(3) Have the services been properly and fully documented?

(4) Were the services correctly coded?

(5) Were the services correctly billed to Medicare?

If you are unable to answer “Yes” to each of the above questions, you have a serious problem.   It is important to keep in mind that there is no administrative appeals process or other effective legal remedy to get off prepayment review.  In fact, there is no “silver bullet,” despite what you have heard or been told.  The only way to be taken off of prepayment review is to show the responsible Medicare contractor that your claims fully meet each of Medicare’s myriad statutory and regulatory requirements for coverage and payment.  To that end, there are a number of preemptive steps a provider can take to reduce the chances of being selected for prepayment review in the first place.

To start, we recommend that you (or your qualified legal counsel) conduct a “gap analysis” of your claims.  In doing so, you will readily identify any possible deficiencies in your medical necessity assessments, coverage, documentation, coding and / or billing activities.  Moreover, you should consider assessing your utilization rate against the local and national average. For instance, for basic Evaluation and Management (E/M) services, are you or your providers billing higher level codes more often than your peers?  Medicare contractors use this data to identify possible outliers who may be engaging in improper coding and / or billing.  Data mining can also be used by contractors to identify potential problem providers who may need to be audited and / or placed on prepayment review.  Keep in mind, should you identify any overpayments when you conduct a gap analysis, you must report the overpayment and return it to the government within 60 days.  Any deficiencies noted in your review can be promptly addressed and added to the risk areas covered in your Compliance Plan.  After taking these steps, you will likely be well situated to respond to any prepayment audits initiated by a Medicare contractor, regardless of whether the contractor is a RAC or another Medicare contractor.

Get Ready – RAC Prepayment Reviews of Medicare Claims Are on the Horizon

(December 19, 2011):

I.          Introduction: 

As you know, RACs play an important role in the identification of Part A and Part B overpayments. Since the inception of the RAC Demonstration Project in 2005, RACs have successfully identified a number of improper claims, denying payment for reasons ranging from mere technical errors to broad concerns about medical necessity.  Unlike other contractors engaged in post-payment audits (such as Zone Program Integrity Contractors and Program Safeguard Contractors), RACs are not compensated on a fixed contract or cost-plus basis.  Instead, their compensation is based on the amount of overpayments they identify (which remain overpayments after any administrative appeals have been pursued). This arrangement has roundly been criticized by providers. Regardless of whether or not you agree with the RAC concept, the program is here to stay.  After reviewing the results of the RAC Demonstration Project, the government expanded the program and made it permanent.

II.         Expansion of the RAC’s Responsibilities:

On November 15^th, 2011, CMS announced that it was initiating a new demonstration project designed to help ensure that Medicare claims billed to the government are medically necessary and otherwise proper before they are paid. RACs will now be performing prepayment audits of provider claims. These reviews will likely be conducted in much the same manner as those currently initiated by other Medicare contractors. With the addition of RAC prepayment reviews, CMS hopes to further reduce the number of improper claims paid by the government each year.

III.        States to be Covered in the RAC Prepayment Demonstration Project:

The “RAC Prepayment Review Demonstration Project” is initially slated to target physicians, hospitals and other Medicare providers in Florida, California, Mississippi, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Missouri.  Implementation of the new pilot project is set to begin in January 2012.

IV.        Impact of Being Placed on Prepayment Review:

Importantly, there is no administrative appeals process covering prepayment audits. As a result, it is not uncommon for providers placed on prepayment review to remain in this status for four to six months or until the provider is able to show the contractor that the services billed are both medically necessary and fully meet Medicare’s coverage and documentation requirements.  Unfortunately, being placed on prepayment review can prove disastrous for providers with a large Medicare patient load.  It can effectively delay payment for several months, even if the contractor ultimately finds that the claims qualify for coverage and payment.

V.         Avoiding Prepayment Review:

Unfortunately, there is no “silver bullet” you can use to completely eliminate the risk of being placed on prepayment review. Nevertheless, there are a number of preemptive steps you can take to reduce the likelihood of such an occurrence.  To start, you should conduct a “gap analysis” of your claims.  In doing so, you will be able to learn whether or not the services you are billing meet Medicare’s medical necessity, coverage and documentation requirements.  Additionally, you will likely learn whether your utilization of services is less than, comparable to, or exceeds that of your peers.  Any deficiencies noted can be promptly addressed and added to the risk areas covered in your Compliance Plan.  At this point, you will likely be well situated to respond to any prepayment audits initiated by a RAC or another Medicare contractor.

Liles Parker attorneys and staff have extensive experience conducting gap analyses and providing compliance guidance to health care providers.  Additionally, our attorneys are skilled in assisting providers who have been placed on prepayment review. For more information, please call us today for a free consultation at 1-800 (475) 1906.

CERT Audits are Serious – Don’t Take them Lightly

(November 23, 2011):

I.             What is a CERT Audit?

The “Comprehensive Error Rate Testing” (CERT) program was implemented as a mechanism for the Centers for Medicare and Medicaid Services (CMS) to assess whether their Medicare Administrative Contractors (MACs) are properly paying claims.  In other words, is a particular MAC failing to identify and deny improper claims?  Alternatively, is the MAC denying claims which do, in fact, qualify for coverage and payment? Essentially, the CERT program serves as an integral management tool for CMS as well as an important feedback mechanism for the MACs. When problem areas are identified, they can be actively addressed by a wide variety of Medicare contractors with audit responsibilities.  Notably, several of the MACs around the country have been aggressively reasserting their roles in the corrective action process.

Essentially, MACs write the checks on behalf of CMS.  As a result, they play an extraordinarily important role in the Medicare reimbursement process. Therefore, when a CERT auditor finds that a MAC has been incorrectly reimbursing providers for claims which may not qualify for coverage, it is very important that the MAC immediately address this system-level deficiency.

II.            Recent Actions Taken by MACs in Response to CERT Audit Findings.

In response to certain CERT audit findings, one MAC recently sent notification to providers of Evaluation and Management (E/M) services explaining that new “stringent corrective actions” will be taken to address some of the more common claims errors identified by the CERT auditors when conducting their reviews of MAC payment practices.  As recent correspondence to a provider reflects, MACs are taking the results of CERT audits quite seriously, and are expanding their program integrity efforts.  As one MAC recently wrote, the contractor stands ready to:

• Suspend a provider if that provider has “too many” payment errors (it does not state how many is “too many”);
• “[R]efer every physician” to that region’s ZPIC if those providers continue to bill for services which may constitute payment errors;
• “[R]efer every physician” to the ZPIC if there is a pattern of past payment errors; and,
• “[C]onduct prepayment reviews” of future claims, up to 100% of a provider’s claims.

To be clear, none of these potential corrective actions represent new authorities.  Nevertheless, the fact that MACs are now reasserting these points is reflective of CMS’ ongoing concerns regarding the prevalence of improper claims.  Indirectly, CMS is making it crystal clear that as the initial recipient and screener of Medicare claims submitted by providers for payment, MACs play an essential role in screening out improper claims and bad providers.  As Medicare’s primary gatekeepers, MACs are responsible for identifying both improper claims and providers who may be engaged in abusive and / or fraudulent practices.

III.           What Should You Do if You Are Notified of a CERT Audit?

Should you receive a CERT audit request for documents from a CERT Documentation Contractor (CDC), it is important to keep in mind that your practice or clinic is not being accused of fraud or wrongdoing.  Fundamentally, a CERT audit is primarily designed to identify deficiencies and mistakes made by Medicare contractors.  Nevertheless, it is imperative that you take a CERT audit request quite seriously.  At the end of the day, it will be you, not the MAC, who is responsible for any overpayments identified as a result of the audit. Moreover, bad results on a CERT audit may lead to further auditing in the future.

IV.          What Actions Should a Compliance Officer Take to Being Audited?

As an organization, if you are subjected to a CERT audit, the “horse is already out of the barn,” so to speak.  Your goal is to review and monitor your organization’s coding, billing and utilization practices on an ongoing basis so that improper claims are never submitted to your MAC in the first place.   In most cases, you can check your MAC’s website to determine if their CERT auditor has already identified certain areas of concern. For instance, one MAC recently reported that out of 508 errors identified in a CERT audit of certain Medicare claims, the contractor found that:

• 311 errors were due to “insufficient documentation.”  Notably, a majority of the errors in this category were because the medical record “did not contain a valid physician’s signature” or because a diagnostic test performed “did not contain a valid physician’s order” or an identification of the provider who rendered the service.
• 132 errors were due to “lack of medical necessity” based on the medical documentation submitted.
• 37 errors were due to “incorrect coding” (primarily related to laboratory testing).
• 10 errors were due to “invasive procedures that were assessed to be without medically necessity.”
• 9 errors were due to an “incorrect procedure code” used when billing the service.
• 6 errors were the result of “billing for services that were not rendered.”
• 2 errors were due to “other errors.”
• 1 error was due to an “incorrect discharge code being used.”

Compliance Officers can take these “general” risk areas, add them to the “practice-specific” risk areas already noted, and take special note of these concerns when conducting internal reviews. The only way to avoid the scrutiny of Medicare’s various administrative contractors (MACs, ZPICs, RACs and CERT auditors) is to avoid payment errors altogether.  While no provider is perfect, the development, implementation and adherence to an effective Compliance Plan can significantly reduce the number of improper claims submitted by a provider to a MAC for reimbursement.

V.            What Actions Should a Compliance Officer Take After Receiving a CERT Audit Letter?

As Compliance Officer, upon receipt of a CERT audit request, you should carefully review the request and take steps to assemble a complete set of medical records and other supporting documentation related to the specific claims at issue.  It is important not only to make sure that your documentation is complete when sending in records to a CERT contractor, but to make sure that compliance is a daily part of your practice. Ensuring that your documentation is appropriate and accurately documents both medical necessity and the level of services performed can greatly assist you in avoiding trouble down the road.

Now, more than ever, it is important that you have an effective Compliance Plan in place.  Your Compliance Plan should explicitly set out your organization’s policies about how to correctly assess the need for, and document the services provided to a Medicare beneficiary. Otherwise, as demonstrated by the tough stance being taken by the MAC discussed above, CERT audits and other Medicare post-payment audits could raise serious problems for your practice.

Liles Parker attorneys represent health care providers in CERT, MAC, ZPIC and RAC audits and investigations.  Our attorneys have extensive compliance experience and can conduct “gap” analyses designed to place your practice or clinic on solid regulatory footing.  To speak with one of our attorneys, call 1 (800) 475-1906 for a free consultation today. 

Medicare Post Payment Audits and the “Average” Provider

(November 16, 2011) Many providers believe that their practice is a normal one – average billings, average patient load, costs of care which are consistent with industry standards – and that they need not be concerned with undergoing a Medicare post payment audit for being a “statistical outlier.” As you may know, Medicare and Medicaid contractors rely heavily on “data mining” to identify potential audit targets. With “data mining,” RACs, ZPICs and other entities conducting Medicare post payment audits can look at historical billing data, as well as billing date from regional and local peers of a particular provider, and determine if that particular provider’s billings appear suspect.

While a provider might think its billing is in line with or below that of its peers, it is very important to remember that the Medicare post payment auditors are experts in “slicing and dicing” the data in so many ways that virtually every provider could show up as an outlier. For instance, perhaps the cost per patient, cost per procedure or cost per service plotted high, or maybe the total number of services per patient was high. For length-of-stay (LOS) providers, perhaps the total number of days of service on average was high or the billings per day ended up being high.

Moreover, even if a provider thinks they run a “tight ship,” a lot of Medicare claim reimbursement is dictated by the medical necessity of the services provided to each patient. For instance, a provider may have a string of highly complex, highly demanding patients, who need more in-depth care. These same providers may have gained a local reputation for handling high complexity cases, thereby further driving up the data “against” them. In any event, Medicare post payment auditors are looking out for high-billing providers and have many ways of interpreting the relevant data to justify their audit decisions.

Liles Parker handles Medicare post payment audit appeals, in addition to other health law matters. For more information or to speak to one of our attorneys, please call 1 (800) 475-1906 today for a free consultation.

ZPICs, PSCs, and RACs are Conducting Audits of SNFs — Skilled Therapy and Skilled Nursing Services Must be Fully Documented and Must Comply with Medicare’s Coverage Requirements

(July 10, 2011):  I.   Introduction:  In response to a report released by the Office of the Inspector General (HHS-OIG) of the Department of Health and Human Services, the Centers for Medicare and Medicaid Services (CMS) recently signaled that it will direct Medicare contractors to more closely scrutinize the billing patterns of skilled nursing facilities (SNFs). In fact, since HHS-OIG released its report, we have noted a dramatic increase in the number of SNF audits being performed by Zone Program Integrity Contractors (ZPICs), Program Safeguard Contractors (PSCs), and Recovery Audit Contractors (RACs). These audits can potentially result in extrapolated overpayments of millions dollars. 

In light of these enhanced audit and enforcement efforts, it is essential that SNFs take steps to better ensure that their actions fully comply with applicable documentation, coverage and payment requirements.  Areas of particular concern identified by ZPICs have included:

II.  Areas of ZPIC Concern:

Certifications and Recertifications. Federal regulations require that a physician certify a patient’s need for SNF services “at the time of admission or as soon thereafter as is reasonable and practicable.” The first recertification must take place by the patient’s 14^th day of SNF care, and each subsequent recertification must take place every 30 days. Providers should ensure that they conduct and document certifications and recertifications in a timely fashion. A number of contractors have refused to accept copies of physician’s orders — including orders for additional or ongoing therapy care — as a substitute for a certification or recertification.

Hospital Documentation. Medicare rules state that all patients receiving SNF care must have received inpatient hospital care for at least 3 consecutive days and be admitted to the SNF within 30 days following discharge from the hospital. Patients must receive SNF care for a condition for which they received treatment in the hospital. At a minimum, providers should obtain the following documentation related to each patient’s qualifying hospital stay: 

Patient history and physical.

All laboratory reports and tests.

All physician orders and progress notes.

All inpatient therapy progress notes.

Patient discharge summary. 

Providers should obtain this information from the discharging hospital as soon as possible after a new patient is admitted to the SNF. Incomplete or insufficient records (especially those that establish a baseline level of patient function) will give contractors ample bases on which to deny your claim.  

Therapy Documentation. All therapy care must be provided under a plan of care established by a physician, nurse practitioner, or licensed therapist. The documentation must also reflect the patient’s diagnosis, anticipated therapy goals, and the type, amount, frequency, and duration of therapy. The documentation should also include the patient’s prior functional ability, rehabilitation potential, and evidence of an expectation for material progress. At a minimum, the therapy documentation for each claim should consist of: 

A treatment plan for each RUG code billed and for all dates of service on the claim.

A log of all therapy minutes that were provided during the dates of service on the claim.

Progress notes to support the look-back period for each RUG code billed as well as the entire payment period for the dates of service. 

Providers should ensure that information from the therapy logs (especially the number of minutes of therapy) accurately reflects the amount of therapy provided and is consistent with the information coded on the MDS. Inconsistent coding will likely result in a denial of the claim, despite the fact that these therapy services were properly provided. 

Nursing Documentation. Under applicable regulations, patients must require skilled care on a daily basis in order to be eligible for post-hospital SNF services. Generally speaking, skilled nursing care is that which is so complex that it can only be safely and effectively performed by professional or technical personnel. Generally, examples of skilled nursing cited by SNF have often included:

Management and evaluation of the care plan;

Observation and assessment of the patient’s changing condition; or

Patient education services.

 SNFs have sought to demonstrate a skilled level of nursing care by documenting the nurse’s ongoing observation and assessment of a patient’s condition. However, in order for observation and assessment to qualify as skilled care, the patient’s condition must such that imminent deterioration is possible. In those cases, observation and assessment of the patient only constitutes skilled care until the patient’s condition is stabilized. Providers should therefore document any and all facts and circumstances which indicate a possible imminent decline in the patient’s condition. Otherwise, a ZPIC deny the claim on the basis that the care given does not constitute skilled nursing care.

III.  Recommendations and Conclusion:  Over the past year, the number of SNFs audited by ZPICs, PSCs and RACs has significantly increased, due in large part to the government’s continuing concern that the services being provided do not qualify for coverage and payment. 

While an audit of your SNF may be inevitable, you can reduce the likelihood of an overpayment through the use of an effective Compliance Plan which includes the use of periodic self-audits designed to identify possible deficiencies which may exist.  Once identified, SNFs must immediately take remedial steps to correct any deficiencies which are identified and modify its practices (and the risk areas within its Compliance Plan) to better ensure that these problems do not reoccur. 

Prior to conducting a review, we recommend that you contact your legal counsel to discuss possible review options.  Working with legal counsel, SNFs should consider working with outside third-party reviewers who are familiar with both ZPIC / PSC / RAC concerns and SNF coverage and payment requirements. While it is certainly important for providers to actively participate in the self-audit, a third party engaged to direct the review may be more objective in their assessments of the documentation than the therapy or skilled nursing providers themselves. Attorneys who are familiar with the risk areas unique to SNFs can also readily identify problems with documentation, recommend strategies for improvement, and work with SNFs to adjust their Compliance Plans accordingly.  Ultimately, the assistance of knowledgeable counsel could help providers avoid (or reduce) future liability it audited by a Medicare contractor.  As a final point, regardless of whether a self-audit is conducted by a third party or by the SNF itself, it is essential to keep in mind that:

 “If it doesn’t belong to you, give it back” – All providers, including SNF must comply with this simple rule.  Should you identify a Medicare or Medicaid overpayment, it must be returned to the government within 60 days. 

 “Documentation of services rendered must be accurate” – Therapy and skilled nursing services must be accurately documented in each patient’s medical records.  It isn’t sufficient to merely state that therapy or skilled nursing services were provided.  As detailed above, SNFs must document aspects of the therapy or services provided which qualify as “skilled” care.  Finally, documentation must accurately describe the work actually conducted and ensure that the duration of services documented is correct.     

Liles Parker attorneys have extensive experience representing SNF and other health care providers in connection with ZPIC audits and / or reviews by other Medicare contractors.  Should you have questions, please give us a call for a complimentary initial discussion of your project or case.  We can be reached at:  1 (800) 475-1906.

The ZPIC Audit and Appeals Process

(March 25, 2011) – Zone Program Integrity Contractors (ZPICs) have established themselves as the preeminent audit tool of the Centers for Medicare and Medicaid Services (CMS), surpassing both Recovery Audit Contractors (RACs) and Medicare Administrative Contractor (MAC) Benefit Integrity units.

RAC and ZPIC appeals follow the same general procedures, but it is important to learn these procedures regardless of whether you engage counsel. Timeframes, both for recoupment and filing appeals, are very strict, and you should ensure that you meet these deadlines.

For more information, please review the Liles Parker “ZPIC Audit and Appeals Process” Chart. Click here: ZPIC Audit and Appeal Process Chart

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