ZPIC – The primary
role of Zone Program Integrity Contractors is fraud detection, prevention, and
correction. ZPIC audits are the direct result of suspected fraud from
complaints and data analysis. ZPICs conduct investigations, audit claims and
are authorized to sanction entities. A subarea is the PSC- Program Safeguard
Integrity Contractors ensure that paid claims were for services provided and
properly documented; for services billed properly, using correct and
appropriate procedure codes; for covered services; and paid according to
Federal and State laws, regulations, and policies.
MAC- The primary
role of the Medicare Administrative Contractor is to serve provider enrollment
for Part A and Part B billing claims. Their focus in the first level of appeals
involves Medicare payment accuracy and review of beneficiary-related facility
and professional claims. MACs process, review, and audit claims, handle
re-determination requests, educate stakeholders and liaison with audit
HEAT- Health Care
Fraud Prevention and Enforcement Action Team is a joint initiative between HHS, OIG, and DOJ; its Medicare
Fraud Strike Force targets emerging or migrating fraud schemes, such as fraud
by individuals posing as health care providers or suppliers.
drug integrity contractors identify potential Part D fraud and abuse through
external sources and proactive methods.
Advantage (Risk Adjustment and RADV); 7 National Committee for Quality
Assurance and HEDIS; 7 State Medicaid Programs; and 7 Payment Integrity
In addition, RAC
compliance is technically separated into Medicare RACs and Medicaid RACs.
Discuss why RAC compliance is a component
of keeping the compliance program up-to-date. The latest RAC Trac Survey
(2016) conducted by the American Hospital Association reveals that 60% of
reviewed claims did not have an overpayment, so the heavy penalties associated
may be having an impact. Crump (2016) argued that audits can be used to improve
clinical documentation with budget savings achieved by a more comprehensive and
cohesive approach to documentation organization. In addition, this field
advocate argued that audits serve as benchmarks when establishing process and
workflow limit areas.
What steps should a
hospital, clinic, etc. take to be prepared for a RAC or other
external audit? According to the American Hospital
Association (2012), the number of Recovery Audit Contractor Audits are
increasing (Manos, 2013). In a review of the Recovery Audit Contractor Audits
and Appeals process for three large medical centers, Sheehy et al. (2015) found
that even though only eight percent (8%) of encounters were audited, over 31%
resulted in an alleged overpayment, with additional findings that overpayment
conclusions had been increasing significantly. Given this disappointing trend, health
care providers need to prepare.
(2014) recommended internal audits and the development of a billing compliance
plan as an umbrella response with procedure-level response including improved
tracking of denied claims and investigation of billing errors. This author also
advocated for staff training and monitoring of regional and national trends and
news. Moore, Rawlings, Gilmer and
Stallings would seem to agree with Stillwell, advocating the same points along
with recommending the formation of a compliance committee, a dedicated point
person to deal with RAC communication, and the engagement of independent
Research Clinical Documentation Improvement
programs and discuss whether or not you recommend a CDI program to aid in the
prevention of RAC denials. Provide a rationale for your recommendation.
that Sheehy et al (2015) found that hospitals appeal 91% of overpayment
accusations and increasing the percentages of judgements in their favor,
Research Clinical Documentation Improvement programs may well be swaying
decisions because the provider can demonstrate that a robust quality assurance
program exists and is effective. The American Hospital Association’s most
recent RAC Trac survey found that only 45% of hospitals are appealing denials
(2016), which is significantly lower than earlier years. In addition, findings
of a 72% successful appeal rate (Manos, 2013) are down to only 27% rate if
reversed denails. Taken together, these findings indicate that the RAC process
is becoming more effective. Towers (2013) notes that one of the main benefits
of a CDI program is to identify activity that occurred but were not documented
in a way that can be coded
compelling reason to implement a CDI program is the expenses associated with
the RAC process, 67% of hospitals spent between $10,000 to $25,000, with 4%
spending over $100,000 (American Hospital Association, 2016).
Tie in all the elements you have learned in
this course and include your new found knowledge.
Some of the
greatest benefits of the Recovery Audit Program is the recouping of award money
to the Medicare program, however, the money represents greater gains in that
the method of loss discover deploys big data analysis rather than costly human
investigation to determine potential losses instead of labor-intensive actual
costs. Providers benefit from a reduced provider burden so that providers with
low denial rates have lower limits.
addition, the program has documented that it has helped increase program
transparency so that providers are sure who to contact for complaints or
concerns. For the Centers of Medicare & Medicaid Services, the program
enhances their oversight by increasing
proactive provision of information so that providers are clear about how to
prevent improper payments and billing.