Following rules set by Medicare is very important for healthcare providers. But unfortunately, they must also always be on guard for ZPIC audits. Because investigations into healthcare fraud are getting more sophisticated, these audits are becoming more frequent as well. A ZPIC audit is an investigation into a healthcare provider’s billing records and practices. It targets Medicare fraud, abuse, and waste. Because these audits are very serious and invasive, providers must prepare for the possibility. The consequences of being unprepared are grave. Financial penalties and exclusion from Medicare are certainly possible.
This ZPIC audit prep guide aims to provide the most important steps for preparing for a ZPIC audit, for identifying easily recognizable prep audit red flags, and preparing for inquiry.
ZPIC audits are among the most serious kinds of audits. More serious and invasive than most, these audits are the result of fraud referrals, and ZPIC contractors are hired by CMS to investigate Medicare fraud and billing noncompliance. Unlike other audits, ZPIC contractors can require an unlimited amount of documentation from the healthcare providers, plus, they can show up unannounced for on-the-spot audits, and if they want to, they can even interview any of the provider’s patients. This unbounded authority is why ZPIC audits are so serious. As such, preparing for ZPIC audits is the most important factor in the healthcare provider’s fraud protection and compliance strategy.
The Importance of ZPIC Audits
ZPIC audits are important in keeping the Medicare system intact because they help keep track of the billing and coding practices of the health providers.
Fraudulent billing practices are unearthed.
ZPIC audits ensure compliance with the Medicare billing guidelines.
ZePIC audits help Medicare avoid improper payments and overbilling.
ZPIC audits provide accountability with the health providers.
ZPIC audits help keep Medicare financially healthy.
Helpless ZPIC audits prep most of the risk and help the health providers to do the ZPIC audits.
ZPIC Audit Preparation a Checklist
Documentation required of a ZPIC audit
Having the required documents is the most important thing in preparing for the ZPIC audit. ZPIC audit documents for ZPIC audit should consist of the essential medical records, billing codes, and documentation of patient care. ZPIC auditors will analyze these documents to find out if billing practices are in accordance to the Medicare guidelines. To avoid any complications, make sure to keep the records current, complete, and well-organized.
The documentation should include:
Medical records, in consistence with the claims that were submitted.
Invoices corresponding to the drugs, supplies, and equipment.
Physician’s notes with records of the diagnosis.
Consent forms and patient agreements.
Failure to provide a complete and well organized set of records without apparent rises of suspicions from a ZPIC audit documentation runs poor outcomes from a ZPIC audit.
2. Create a Healthcare Provider Audit Compliance Plan
Audit readiness in a healthcare organization starts with having a well-structured provider audit compliance plan. That includes detailing how you plan to supervise compliance with CMS regulations and the procedures to ensure correct coding, documentation, and billing. Internal audits can help sustain your practice’s compliance as well as help discover and resolve issues that may spiral into larger issues in a ZPIC audit.
Your employees must be trained in compliance and the necessity of procedure compliance to reduce the risk of fraud. An updated compliance plan shows auditors that your practice takes compliance seriously.
3. Execute a Plan for Regular Internal Self Audits
Audit risk mitigation healthcare starts with having the right mindset. Regular self-audits help you discover the discrepancies and improvements necessary to ensure you avoid the ZPIC audit. Make sure you review your Medicare claims and coding practices periodically to ensure they meet the Medicare coverage guidelines, Local Coverage Determinations (LCDs), and National Coverage Determinations (NCDs).
Addressing these concerns preemptively eliminates the chances of receiving a ZPIC audit and instantly builds a history of compliance that will prove useful if an audit must be dealt with down the road.
4. Reaction to a ZPIC Audit’s Response Letter
When you get a response ZPIC audit letter, the first thing to do is act fast. The audit has started once you receive ZPIC’s initial letter, which is a request for certain specific documentation. The letter will most likely contain a clearly outlined description of the documents that will be needed for the audit and the deadlines to which they must be submitted.
Be sure to do the following:
1. Verify the information: Thoroughly check the date of the audit, what documents are needed, and the due date.
2. Arrange documentation: Don’t do it too fast, but rather accurately collect the required documents.
3. Talk to an attorney: Don’t experience the process alone, and you should consult an attorney if you have an uncertainty with some of the documents, whatever the situation may be. It is a good idea to have a Medicare audit defense attorney to help with the complex parts of the audit, and to make sure you are capturing everything that needs to be important.
Common ZPIC Audit Triggers and Red Flags.
Preparation includes important facets of ZPIC audits. ZPIC audits happen in response to something in particular, they do not take place without reason. There are many red flags that count for ZPIC audits.
Strange Billing Practices: There are larger than average discrepancies in the billing than the rest of the acceptors, submitting claims for some services or treatments at a higher than average rate.
Overuse of services: There are more services billed to a patient than other medical professionals that are in the same region or have the same specialty.
Haphazard or Lack of Documentation: Patient records are incomplete or missing altogether. Auditors contend that this is poor documentation.
Billing Errors: Auditors contend that if there is a lack of attention to coding billed are billing errors.
Keep billing practice in a way that is correct and consistent with the Medicare billing rules to not get flagged.
Appealing ZPIC Audits.
If the ZPIC audit results in findings of some combination of overpayment or some type of fraud, you certainly have an Option to Appeal. Several elements are involved in the ZPIC audits appeal process: Redetermination, Reconsideration, and if applicable, some type of administrative an ALJ hearing.
Things to Remember During Your Appeal
Compiling defecting evidence: Anytime further evidence or documents can be introduced, either to help the case or to further scrutinize the audit and the audit documentation, the case is open to further evidence, and the odds of winning increase;
Engaging with the right type of attorneys: Defending against Medicare audit attorneys can help you make the most of the appeals process, streamline the process, and help you present your case;
Though time-consuming and potentially frustrating, most things can be done to change the outcome of a ZPIC audit to be positive or at least mitigated if handled correctly.
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Things You Can Do to Cut Risk
ZPIC audits do not happen randomly and trigger complaints, but you can take several steps to minimize your risk. Proper planning, documentation, processes, and billing practices are best practices. If done properly, ZPIC audit avoidance is a measurable outcome. In addition, compliance plans with periodic self-assessment audits can help keep your practice audit-ready.
Healthcare audit risk mitigation is a process driven approach. It is equally the positive environment and organizational culture which must be aimed at compliance and responsibility as the practices and processes for managing risk. It is the positive organizational environment which will result in your practice being audit available.
ZPIC audits can be challenging in the healthcare landscape, but ZPIC audits can be navigated with the right measures in place. ZPIC audits can be handled without the loss of time and efficiency by utilizing the ZPIC audit checklist, and maintaining honest and accurate documentation, and legal guidance can help save your practice from the numerous repercussions of an audit gone awry.
Success hinges on the foreclosure of an audit gone awry without sacrificing time and efficiency, so start taking the necessary steps today to implement ZPIC audits and to ensure your practice is ready for anything to come.