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ZIPC audits target potential fraud in Medicare billing.

The Centers for Medicare and Medicaid Services (CMS) has a new audit program: the Zone Program Integrity Contractor (ZPIC) Audits. During the past year, CMS started to implement this program to wrestle with the large problem of fraud and abuse.

ZPIC audits will be aimed at combating fraud, unlike the Recovery Audit Contractor (RAC) audits that simply seek overpayments and underpayments made to providers who treat Medicare patients. Also, unlike the RAC audits, ZPIC audits will not be random. ZPIC audits are based on fees and medical necessity, while RAC audits only assess whether charges were overpaid or underpaid. The ZPIC auditors will already have an objective in mind when they approach a practice. In other words, if a ZPIC auditor contacts a physician’s office, he or she already think there is evidence of coding and billing irregularities. Situations these auditors look at include:

• Medical necessity: There must be documentation of medical necessity for all services provided to patients. In addition, a procedure must meet the medical need of the patient (e.g., correct diagnosis, procedure must meet frequency guideline).
• High utilization of a procedure: New technologies are continually being developed, but a physician must demonstrate the medical necessity for the service.
• Cloned medical records: Providers should be careful that their medical notes do not appear to be cloned or are “cookie cutter” notes. Providers should be mindful of this when using an electronic health record.

Currently, ZPIC audits are being performed nationwide and are divided into seven zones:

1. Zone 1: California, Nevada, American Samoa, Guam, Hawaii, and the Northern Mariana Islands
2. Zone 2: Alaska, Washington, Oregon, Montana, Idaho, Wyoming, Utah, Arizona, North Dakota, South Dakota, Nebraska, Kansas, Iowa, and Missouri
3. Zone 3: Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky
4. Zone 4: Colorado, New Mexico, Oklahoma, and Texas
5. Zone 5: Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, Tennessee, Virginia, and West Virginia
6. Zone 6: Pennsylvania, New York, Maryland, Washington DC, Delaware, Maine, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire, and Vermont
7. Zone 7: Florida, Puerto Rico, and U.S. Virgin Islands

ZPIC auditors can show up at a practice without notice and physician practices must comply with their request for medical records. If a practice chooses not to comply with a request, Medicare has the right to suspend the provider’s Medicare number immediately—resulting in a provider’s inability to submit any charges for Medicare patients until the matter is resolved.

Things to know about ZPIC audits:

• They are never random;
• The service is targeted through data analysis, post-payment audits, patient complaints, peers, and/or discontented employees;
• There is a 30-day time limit to address appeals; and
• Medical necessity of a service is determined by local coverage determinations and/or national coverage determinations.

It is important that physicians and their staff know and understand their rights when it comes to appealing an audit. For a detailed explanation of how to appeal an audit, see “Audited by a Recovery Audit Contractor—Now What?” in The Rheumatologist (December 2010, p. 19, or online at www.the-rheumatologist.org/details/article/973155/.html).

A ZPIC audit is not a death sentence for a practice if the practice is in compliance with all coding and billing guidelines and all documentation for services provided will support medical necessity.

For additional questions or concerns about audits, contact Melesia Tillman, CPC, CRHC, CHA, at (404) 633 -3777, ext. 820, or [email protected].

Dealing with a Short-Staffed Day

The phones are already ringing, the appointment schedule is jam packed—and you just learned that today you’ll be short staffed. Although stress and anxiety are about to kick in, here are some practical suggestions for dealing with a short-staffed day:

1. Focus: Although there might be a million things to do, focus on what must be done today. Providing excellent care to the patients is goal number one.
2. Rearrange the work: Once you know the day’s priorities, pull the team together and let them know what is happening. Be honest with staff and identify the biggest challenges, seeking input on how best to move forward.
3. Communicate: Although there might be tension and stress, any and all communication should come with respect and gratitude.
4. Have a positive attitude and smile: While it’s no fun to take on extra work, a positive attitude and being a team player help everyone to get through the day.
5. Schedule breaks: Coordinate appropriately with staff to make sure that no one gets burned out. Breaks might have to be rescheduled, but everyone should be able to walk away from an area to stretch or eat. Proper coordination is the key.

In addition to these suggestions, employers can create policies and procedures to ensure that the practice is always fully staffed and ready to serve patients. Practices that invest in cross-training staff are better able to weather employee absences. For tips, see “Cross-Train Staff to Improve Practice Management,” in The Rheumatologist (April 2011, p. 30, or online at www.the-rheumatologist.org/details/article/1052257/.html).

If you have questions related to practice management, contact the ACR’s practice management department at (404) 633-3777 or [email protected].