ZPIC Audits- Do I need a CPA?
It depends? If your CPA a Medicare Cost Report expert? If the answer is yes, he or she probably prepared your annual Medicare Cost Report or Medicaid Cost Report and getting them involved as as soon as possible is a good idea during ZPIC Audits.Wow what a feeling!!
I have talked to potential clients as they are actually having chest pains and snacking on nitro tabs or spray as they describe this over the phone to me, they have been to the hospital already and continue to have the pains weeks later. ZPIC Audits are is indeed very stressful.
You have just been selected for a ZPIC Audits amongst an elite group of many who during the last 36 months have submitted via your billing, OASIS, Service Utilization, et al.. to the folks at CMS, created a data profile and pattern, which has been confirmed by the computers as 90% or greater chance it contains errors allowing them to recover several million dollars from you. (More of that another time)
The data is so compelling that it leaves CMS no other option than to validate what your doing. Via a post payment review.
So you have a letter.
CMS is fishing for money.
No denial of payment has been made as of yet.
A lawyer will do what at this point?
A consultant will do what at this point?
What can I the agency owner do for FREE, The answer is an amazing amount, and most owners properly coached need very little intervention until the midpoint of the process.
It is actually more important to build a financial rainy day fund at this point than spend like a sailor.
Everything that needs to be done at this point can be done by you, auditing of the census and the charts to look for the data patterns that triggered this fiasco, and the documentation patterns that will be denied, and perform a sample extrapolation from your global universe of claims to validate and assess your liabilities.
ZPIC Audits rather simple low-level activities.
So we now know that if you’re the recipient of this type of probe there will be financial losses at some point in time. Certainly not until charts are reviewed, as the law does not allow for the debit of money, until charts are approved and or denied.
So calm down take a deep breath this is not the end of the world, but ZPIC Audits it will not go away either. Some of you will need to go to the gym and work it out, others will resort to a few drinks whilst others will bury their head in the sand.
I have actually been in agencies that did not “get it” even though the pattern or trend was imminently clear to me. Too often owners and administrators really do not know the home health Conditions of Participation and documentation requirements for billing. What generally occurs is that the owner or administrator delegates “auditing” to a nurse or group of nurses who may understand basic documentation requirements but who also are very familiar with the clinical staff and often equally familiar with patients. They frequently “read between the lines” when auditing – and if in addition they do not know the requirements for skilled care they are likely to miss the point. Some documentation issues can be at least partially mitigated if identified and addressed appropriately. A ZPIC auditor will not read between the lines. The major areas of concern will of course be the agency’s understanding of what is required for adequate documentation of therapy provided, REASONABLE goal setting and skilled nursing “observation and assessment”. (Hello, now we even have separate billing codes to distinguish the types of care provided – how’s that for an audit edit set up?). Also there are many agencies who use “managment and observation” as a reason to recertify 85% of their patients often for multiple episodes without documentation of significant clinical issues requiring skilled nursing. Many agencies believe that one or two aberrant blood pressures with no change in medications or other treatment constitute the need for ongoing “observation and assessment”.
Maybe it is too soon to call an attorney when the letter arrives but if there is any chance of lessening the impact an ZPIC Audits may have – they must make sure they understand the rules if they are going to adequately respond to the audit requests yourself.