ZPIC Audits ■ Medicare Audits

UPIC / ZPIC Referrals of MDs and NPs to State Boards!

You aren’t paranoid, your utilization, coding and billing practices are, in fact, being watched. The Centers for Medicare and Medicaid Services (CMS) currently utilizes Zone Program Integrity Contractors (ZPICs) to serve as program integrity contractors. You may have never been audited, been contacted by, or even heard of ZPIC. Nevertheless, that doesn’t mean that they aren’t monitoring your business practices on an ongoing basis.

ZPIC Audit: Will Your Case be Referred to DOJ or HHS-OIG for Fraud?

ZPIC Update: The Impact of Being Placed on Medicare Prepayment Review.

Medical Director Agreements: Compensation Arrangements are Under the Microscope by HHS-OIG

After a hiatus of almost a year, the Department of Health and Human Services, Office of Inspector General (HHS-OIG) has published a new “Special Fraud Alert” entitled “Fraud Alert: Physician Compensation Arrangements May Result in Significant Liability.” As this alert makes crystal clear, physicians who serve as medical directors for home health agencies, hospices and other organizations must exercise care to ensure that the business relationship does not violate the federal Anti-Kickback Statute. This article briefly discusses the potential criminal, civil and administrative liability you may suffer if your Medical Director arrangement does not fully comply with the law.

New Medicare Penalties with Quality and Safety Incentive Programs

The three Medicare quality and safety incentive programs, established under the Affordable Care Act (ACA) that will take effect this year are the Hospital Value-Based Purchasing (VBP) Program, the Hospital Readmissions Reductions Program, and the Hospital-Acquired Condition (HAC) Reduction Program.

Understanding Prepayment Review in 2015

One of the most recent trends involves pre-payment review of claims. In this process, government contractors will review a claim for problems before the claim may be paid. Unlike the traditional postpayment review process, if a health care provider is placed under prepayment review, there is very little you can do other try to identify the nature of deficiencies noted so that remedial action can be taken. Moreover, health care providers in prepayment review face expensive complications, including possible exclusion from Federal healthcare programs, if the problems which caused them to be subject to prepayment review go uncorrected.

CMS Guidance on the Role of the Medical Director

Medical directors act as important leaders for long term care facilities and help them provide quality care. CMS requires all long term facilities to designate a physician to serve in this role in order to receive Medicare payments for services provided. That practitioner must be currently licensed in the State(s) in which the facility(ies) s/he serves is (are) located.