Carla J. Cox
Jackson Walker L.L.P.
cjcox@jw.com • 512-236-2040
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Zone Program Integrity
Contractors (ZPICs)
• ZPICs were called Program Safeguard Contractors
(PSCs)
• 7 Zones:
– Texas, Colorado and Oklahoma are in Zone 4
– Health Integrity is the ZPIC for Zone 4
• Contractor paid fixed rate ($84,928.432.00), but may receive bonus for quality
• CMS paid over one half of a billion on ZPIC contracts
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ZPICs
• ZPIC reviews the following programs:
–
Medicare Part A
—Hospitals, Home Health, and Hospice
– Medicare Part B —Fee-For-Service, Office
Visits, X-Rays, Blood Tests, Ambulance
Services, etc.
–
Durable Medical Equipment (DME)
–
Medicare Medicaid Data Match Project
—
Partnership between state Medicaid agencies,
CMS, and law enforcement officials to identify improper Medicare and Medicaid billing and utilization patterns
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ZPICs
• ZPIC tasks:
– Performing Data Analysis and Data Mining
– Conducting Medical Reviews in Support of
Benefit Integrity
– Supporting Law Enforcement and Answering
Complaints
– Investigating Fraud and Abuse
– Recommending Recovery of Federal Funds through Administrative Action
– Referring Cases to Law Enforcement
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• Examples of ZPIC abuses against providers:
– Deficient ZPIC Auditor Qualifications
• Auditors are not required to have any experience in the medical, therapeutic, or nursing professions
• “Lack of medical necessity” determinations by auditors not reviewed by physicians or persons with a health care background
– Restrictions on Presence of Attorney or Corporate
Officer
• Audits are scheduled unannounced and auditors insist on employee interviews without allowing attorneys or corporate officer time to get to facility to monitor employee interviews
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• Examples of ZPIC abuses (con’t):
– Unreasonable Response Deadlines
• Auditors demand “immediate” access to voluminous records
• Demand immediate access to employees for interviews
• Place unreasonable turnaround times on provision of copies
– Unreasonable Scope of Records Request
• Section 1833(e) of SSA states that Medicare auditors are only entitled to “information as may be necessary in order to determine the amount due” to a provider
• ZPIC auditors have requested documents such as credit card statements, board meeting minutes, profit/loss statements, and other financial information in addition to patient records
• Number of records that can be requested is unlimited
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• Examples of ZPIC abuses (con’t):
– Delays in Audit Findings
• Despite wanting immediate provider turnaround on record production requests, auditors are not in a hurry to produce findings
• Auditors have no federally imposed requirements to provide findings in a timely manner
– Payment Suspensions Prior to Audit Findings
• ZPIC may request the MAC to suspend Medicare payments pending the issuance of findings and MACs appear to be indiscriminately complying with such requests.
– The Good News?
• Most examples are from the Florida ZPIC
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• ZPIC Audits and Appeals
1. ZPIC Review
– ZPIC requests records either on-site or via mail
– No limits on number of records
– Providers have 15-30 days to respond (usually no extensions)
– Payments may be suspended by MAC prior to notice of findings (based on “credible allegations of fraud”)
– Findings can take between 6 and 18 months
– Provider will receive a notice/demand letter from MAC
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• ZPIC Audits and Appeals (con’t)
2. Demand Letter and Rebuttal
– If overpayment to provider is found, demand letter will impose recoupment
– Recoupment may begin 41 days after the date of the demand letter
– Rebuttal must be filed with ZPIC (not with
MAC) within 15 days of date of demand letter
– Rebuttal not a prerequisite for appeal
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• ZPIC Audits and Appeals (con’t)
3. Redetermination
– Must be filed within 30 days of date of demand letter in order to delay recoupment
– In order to be timely request for redetermination must be filed within 120 days of receipt of demand letter
– MACs have 60 days to issue a decision from date of filing
– MACs almost always side with ZPIC
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• ZPIC Audits and Appeals (con’t)
4. Reconsideration
– Must be filed within 60 days of date of redetermination decision to delay recoupment
– Must be filed within 180 days of receipt of redetermination decision in order to be timely
– All documentation must be filed by this stage of appeal
– Request for reconsideration is filed with
Qualified Independent Contractors (QICs)
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• ZPIC Audits and Appeals (con’t)
5. ALJ Appeal
– Must be filed within 60 days of reconsideration decision
– If reconsideration decision is partially favorable, may appeal unfavorable portion within 60 days of revised overpayment notice
– Appeals filed with Office of Medicare Hearings and Appeals (OMHA)
– It usually takes several months to have a hearing and get an ALJ decision
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• ZPIC Audits and Appeals (con’t)
6. Medicare Appeals Council Appeal
– Must be filed within 60 days of receipt of ALJ decision
– Appeals Council reviews ALJ decision de novo and generally rules in favor of claims denial
• Example: Provider appealed a partially favorable decision by ALJ. Appeals Council overturned ALJ and ruled that both the rehab therapy and nursing services provided failed to satisfy the applicable
Medicare coverage criteria. Therefore, all claims were denied.
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• ZPIC Audits and Appeals (con’t)
7. Federal District Court Appeal
– Must be filed within 60 days of the receipt of MAC decision
– In order to request a review by a Federal District Court, the amount remaining in controversy must meet the threshold requirement. This amount is recalculated each year and may change. For calendar year 2013, the amount in controversy threshold is $1,400.
– Standard of review: The findings of the Secretary of
HHS as to any fact, if supported by substantial evidence, are conclusive .
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– Appeal is final unless court remands

ZPICs
• Review usually starts based on data with
CMS
• Can arrive on very short notice (1 hour or less)
• Unlimited number of records can be reviewed
• Can put provider on 100% payment review
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