(July 16, 2010): If there were ever any doubts that ZPICs are going to make their presence known in South Texas now that they have replaced PSCs,those doubts can be put to rest. Health Integrity LLC, the Zone 4 contractor, is proving to be an active and aggressive auditor of physician practices, physical therapy services, home health care, and other types of Medicare covered treatment in the region.
Even in a nationwide environment of intensifying oversight, Medicare providers in South Texas are under particularly close scrutiny. According to a study by the Dartmouth Institute for Health Policy & Clinical Practice, updated as recently as May 12, 2010, "even after price adjustment, Miami and McAllen Texas are the highest cost regions in the country." (Emphasis added). And don’t forget that ZPICs are essentially being "graded" based on the amount of overpayments recovered, along with the number of enforcement actions handled and referred to law enforcement.
As many Medicare providers in South Texas can attest, the folks at Health Integrity (Zone 4 – ZPIC) are becoming a familiar sight in their offices and clinics -- reportedly conducting extensive on-site audits with little if any notice. To their credit, most providers have reported that Health Integrity’s representatives have been reasonable in their requests when conducting an on-site review, typically taking a sample of certain records and asking that the remaining records be sent within a reasonable amount of time after the visit. Nevertheless, providers should take care when responding to the ZPIC’s requests for information. While a provider may have an obligation to cooperate with the ZPIC, you should contact your counsel to ensure that your rights are protected while still fully meeting your obligations as a Medicare participant.
Moreover, we have found that ZPICs are increasingly placing home health providers (and others) on pre-payment review. This can effectively delay a provider’s cash flow up to six months (and in some cases even longer). Given the GAO’s recommendation last month that CMS put more emphasis on automated pre-payment review, we expect to see this trend continuing precipitously upward.
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