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ZPIC Audit Avoidance for Home Health Providers

by admin on November 30, 2017 No comments

zpic audit medicareBy: Matthew Fischer

Medicare beneficiaries are generally entitled to coverage for care received by a home health agency.  However, home health providers can expose themselves to large overpayment demands from Zone Program Integrity Contractors (ZPIC audit) if the face-to-face (FTF) encounter requirements for home health certification are not strictly followed.  On an increasing basis, FTF encounters have been the target of ZPIC review.  Providers view this position as an effort to use home health agencies to police the industry.  On the other hand, contractors see this as part of their mission to identify cases of suspected fraud and recoup inappropriate payments.  Thus, it is imperative that home health providers fully understand the requirements in order to withstand contractor scrutiny.

FTF encounters are required to be conducted no more than 90 days prior to or within 30 days after the start of home health care.  Most importantly, increased scrutiny is being placed on who performs the FTF encounter.  Under Medicare regulations, only the 1) certifying physician, 2) physician who cared for the beneficiary in an acute or post-acute facility, or 3) qualified non-physician practitioner (e.g. nurse practitioner) working in collaboration with a certifying physician or acute/post-acute physician may perform a FTF encounter.  Additionally, the entity performing the FTF encounter cannot be employed by or have a financial relationship with the home health agency.

In tandem with provider requirements, documentation requirements are another favorite area of inquiry.  Specifically, the certifying physician and/or acute/post-acute care facility medical records must include the actual clinical note for the FTF encounter visit.  When pre or post-payment reviews are conducted by ZPICs, reviewers are looking for 1) whether the encounter occurred within the required timeframe, 2) whether the encounter was related to the primary reason the beneficiary needs home health services, and 3) whether the encounter was performed by an allowed provider type.

With reimbursement reductions set for the future and the introduction of CMS’ recent proposed rule to change the home health groupings model, it is important for home health agencies to ensure all requirements are met to avoid denials of payment.  Through strict adherence to the regulations, home health providers will be able to retain revenue and avoid the costs of dealing with drawn out ZPIC audit document requests and appeals.  However, if an unfavorable review results or demand letter is received from a ZPIC audit, providers should seek experienced counsel to mitigate any potential loses and preserve their bottom line.

In need of help regarding zpic audits home health? Medicare can certainly be a tricky area as it provides coverage for millions of people and has a lot of moving parts. Sometimes, things can get a little confusing and that’s when you want to make sure that you’ve handled everything correctly, done everything by the book and put yourself in the best possible situation for a favorable outcome. It’s important to remember that healthcare in the United States, especially in Florida, is always a hot topic as well. There are constant rules and policies that are being changed and it can feel next to impossible to keep up with them.

This is one of the reasons you need to have a legal team watching your back, not just a lawyer. The fact is that there are so many areas of law that fall under the medical umbrella and you do not want to miss a single thing. Even the way you market your business is a completely different situation when you are talking about a company that deals in the medical field which is why you cannot take anything lightly. Training your employees, agreements your patients have to fill out, how you market yourself, how you keep patient information secure and other areas need a lawyer who has experience handling these types of cases. That’s why, rather than trying to find a one-size-fits-all attorney, you need to work with the best firm in town.

The Florida Healthcare Law Firm has handled zpic audits home health and other legal matters for our clients for decades and can help you with this and any other situation you need assistance with. If you are not sure whether this matter can be resolved online, we encourage you to call us to schedule an appointment so that you can get real answers and learn what your options are.

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