After a ZPIC Audit: How to Get Your Overpayment Reduced or Eliminated

overpayment reduced

If your organization has been the subject of a ZPIC audit and you’ve been found to have filed fraudulent or erroneous Medicare or Medicaid claims, you may be asked to repay the overpayment. This overpayment amount can be substantial, especially if it is extrapolated. However – you may be able to get the debt reduced or even completely eliminated. Here’s how to get your overpayment changed to something you can handle after an audit.

Lessening the Burden of Overpayment

The first thing you should do when you discover that you’re to be the subject of a ZPIC audit is contact an attorney. A qualified attorney can help your organization through the complicated audit and appeals process. And in the unfortunate event that you’re found to owe an overpayment, he or she can help you minimize the burden of this debt. Rather than suffering through payments you can’t afford and letting it bring down your business even further, let us help investigate whether you have other options.

In most cases, if your business has been found to have been overpaid, you’ll need to work on paying back what is owed. However, if the payment seems to be difficult to manage, you do have options. You may be able to reduce or eliminate your overpayment based on several considerations, including:

  • Whether the ZPIC provided the appropriate information regarding its findings
  • Whether your clinical findings were correct
  • Whether the ZPIC reviewed and applied all of your provided documentation correctly
  • Whether the opinion of a clinical expert or physician was needed, and if so, whether it was sought
  • Whether the ZPIC was able to show a high or sustained error rate

Other considerations might include whether you were subject to a prior educational intervention that did not succeed, or whether the ZPIC used appropriate sampling and statistical methods.

In any event, it will be best for your business and staff to consult an attorney. Your attorney can evaluate your case on the basis of all of these considerations. Furthermore, they may be able to challenge the ZPIC’s methods and extrapolations in order to reduce or eliminate your overpayment burden.

Speak with an Experienced Attorney at Oberheiden & McMurrey, LLP

Dealing with and addressing any part of a ZPIC audit can be confusing and complicated. Fortunately, you don’t have to attempt to navigate this process alone. A qualified and experienced legal team can help you manage an overpayment and may even be able to help you get it reduced or eliminated entirely. Let our attorneys help you and your business through the ZPIC audit process, whether you have just received notice of an investigation, or are working on an appeal.

To learn more about a ZPIC audit, overpayments, and appeals, you can speak with one of our experienced attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

What to Do About Medicare Overpayments

medicare overpayments

One of the mistakes that organizations make involves Medicare overpayments, whether intentionally or accidentally. If, despite your best efforts to remain in ZPIC compliance, you find that you have received more money than you were owed for a Medicare claim, don’t panic. The world hasn’t ended.

The best thing to do if you’ve received a Medicare overpayment is to give back the extra money. You have 60 days from the date an overpayment is identified to repay the money. However, while it might be tempting to just keep the overpayment and ignore it, the consequences that might follow are usually not worth it. Instead, here’s what to do if you’ve received more than you should have.

Return What Doesn’t Belong to You

If you think you’ve received a Medicare overpayment, it’s usually best to consult your attorney immediately so you don’t make any mistakes. He or she will be able to review your documentation and ascertain whether you have, in fact, been given an overpayment. If you have, returning the extra money should be sufficient to absolve you of Medicare fraud suspicion.

Sometimes providers are granted overpayments through no fault of their own – but an honest provider returns the money. Keep in mind that there are severe consequences for Medicare fraud and keeping an overpayment can be considered fraudulent.

What to Do If You Find that the Money Should Be Yours

An overpayment doesn’t always mean fraudulent activity. It also doesn’t mean your business shouldn’t have received the higher payment. It’s possible you are entitled to the extra payment. If your attorney reviews the claim and finds that the evidence suggests that you’re owed the money you’ve been paid, you still have the right to appeal the denial of a claim.

Many providers think it’s best to simply pay back the money Medicare wants in order to resolve the case quickly. When it’s a small amount of money, it may seem easier just to fork it over than deal with the expense, trouble, and time of appealing the ZPIC’s denial.

However, allowing ZPIC to deny a claim that shouldn’t have been denied can reflect poorly on your organization. Every ZPIC denial raises your error rate, and the higher your error rate, the more likely you are to be audited in the future.

An Experienced ZPIC Attorney Can Help

Although you might not think something like an overpayment warrants a meeting with an attorney, it’s in your best interest and safer for your business to find out how to handle the extra money. It is never a good idea to just keep the overpayment without investigating why you have received it. And, to ensure you aren’t later charged with fraud, an attorney should investigate the details.

To learn more about a ZPIC compliance and Medicare payments, you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

How to Foster a Culture of ZPIC Compliance in Your Organization

zpic organization compliance

Although there isn’t always any way to avoid a ZPIC audit, there are ways you can protect your business and employees a little more. One of the ways to do this is to foster a culture of compliance in your organization from the very beginning. This might seem fairly simple. However, if you aren’t sure of the regulations involved or the mistakes that might lead to serious consequences for your business, you might be more at risk than you think.

If you’re worried about the possibility of a ZPIC audit you may be able to fend off trouble by implementing a ZPIC compliance plan in your organization. If you can get your clinical and administrative staff to make compliance procedures a part of every Medicare claim, you’ll be fully prepared when it comes time for a ZPIC audit. But how exactly can you foster a culture of ZPIC compliance in your organization?

First of All – Know the Regulations

One of the most important parts of ensuring compliance is possessing knowledge of the regulations. You simply must know them. Otherwise, it’s far too easy to make mistakes and not even realize it. ZPIC audit reviewers have been increasingly active in recent years, but you can protect your organization from claim denials by making sure every member of the team understands the regulations and statutory provisions involved in billing, coding, and documenting Medicare claims.

This means, establishing sound records management procedures that involve staff members at all levels of the organization. What can clinical staff members do to ensure regulatory compliance? What can administrative staff members do? Helpful ways to ensure everyone in your organization is knowledgeable of regulations include the following:

  • Provide plenty of training and continuing education opportunities for all staff members. All members of the team need to learn the intake and records management processes needed to ensure regulatory and statutory compliance.
  • Make sure that training efforts emphasize the importance of ZPIC compliance, both from a regulatory and ethical standpoint.
  • Offer employees incentives for participating in continuing education and training opportunities, so that they can keep their skills fresh.
  • Your messages should be positive, consistent, and ever-present in the organization, so that regulatory compliance procedures are never far from employees’ thoughts.

Speak with an Experienced ZPIC Compliance Attorney Today

Even if you have taken measures to ensure everyone in your organization is prepared and compliant, you could still face a ZPIC audit. However, if you take steps to prepare before an audit happens, you have a better chance at a positive review. If you aren’t sure how to set up a culture of compliance, our attorneys may be able to help answer some of your questions and navigate the process on your behalf.

To learn more about ZPIC compliance, audits, and appeals, you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

Here’s What You Need to Know About ZPIC Investigative Methods

zpic investigative methods

When a ZPIC investigates your organization for Medicare fraud, it will conduct multiple types of investigations to determine whether the alleged fraud occurred, and its magnitude. ZPIC reviews will also be used to determine whether Medicare payments to your organizations were appropriate, even if there is no evidence that you committed fraud.

Although it sounds intimidating and overwhelming, the investigation might be less painful than you imagine. To give you an idea of what to expect, here is a look at some of the investigative methods a ZPIC may use.

ZPIC Audit Investigative Methods

Often, the ZPIC will review a sample of the claims you have submitted recently to look for evidence of unjustified payments or fraud. Such a review may include requests for documentation or other evidence.

The ZPIC may also interview beneficiaries, usually by telephone. You needn’t worry about the ZPIC interviewers causing your patients any alarm. The purpose of the interview is to determine whether a questionable claim is a one-time error.

Additionally, the ZPIC auditors may look for comparable Medicare violations in the past, or instances in the past when you have been contacted by another Medicare contractor regarding such violations. These could include warning letters, educational letters, or contact reports.

Other investigative methods could include:

  • Data analysis and analysis of procedures performed
  • Random validation checks of the licenses of physicians in your organization
  • Reviews of telephone calls or written questionnaires confirming the need for DME or home health services

Investigative methods can also include the comparison of practice and billing trends against local, national, and regional trends, as well as review of certificates of medical necessity. These investigative methods will help the ZPIC determine whether fraud has taken place.

There are other methods that could be part of the investigation. In order to ensure you are prepared as much as possible, it’s important to have a legal team on your side who have been through the process. Although the investigation itself can be scary, it can be less stressful for you and your staff if you have people who have experience with ZPIC audits on your side.

Qualified ZPIC Attorneys at Oberheiden & McMurrey, LLP

Fortunately, you don’t have to navigate the investigation or the ZPIC audit alone. In fact, it’s best for your business to consult a qualified ZPIC audit attorney as soon as possible. If you have been contacted about a ZPIC investigation, you should call us immediately for a consultation. Don’t risk making serious mistakes or accidentally failing to provide the information requested.

To learn more about a ZPIC audit and what you can expect throughout the investigation, the audit, and even the appeal process, you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. You have a lot on the line and should make sure you have someone on your side to represent your best interests. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

What to Do if You Get a ZPIC Demand Letter Without a Record Request

zpic demand letter

If you get a ZPIC demand letter without a record request that means you’ve been the subject of an automatic review. Automatic reviews are implemented in order to detect obvious mistakes in billing. They’re usually done by computer and are typically fairly simple to handle. The good news is, you might not have to do anything further.

However, in order to ensure you address any concerns and requests thoroughly, you’ll want to let an experienced lawyer take a look at your demand letter. Otherwise, here’s a brief explanation of what you can do if you receive a demand letter that is not accompanied by a record request.

Review Your Records for a Mistake

Make sure you fully understand the reason why the claim or claims were flagged in the review. Go back over your own records to look for the mistake. This step is especially important in addressing the demand letter and preventing your business from facing costly consequences. Review your records thoroughly. If you aren’t sure what to look for in reviewing your documentation, consult one of our attorneys.

Find Out Why the Overpayment Was Made

Common reasons why overpayments are flagged in an automatic review include:

  • The service provided cannot be covered by Medicare or Medicaid.
  • The service is “medically unbelievable,” meaning that it doesn’t make sense from an anatomical standpoint, or is medically unreasonable.
  • You have failed to respond to a record request for a previous, complex review in a timely manner.

There could be a number of other reasons an overpayment was made so make sure you track down exactly what might have happened.

Decide Whether You Want to Appeal

Do you want to appeal the findings? Talk to your attorney about whether an appeal is the best decision for you. Appeals can be time-consuming and costly, but having a history of claim denials can make you more vulnerable to future audits.

Take Action

You’ll need to take corrective action right away to fix your mistake and keep your organization from attracting any more scrutiny. If you are not appealing the decision, pay the overpayment. A payment plan may be possible, or you may be able to get some of the debt forgiven.

Contact Experienced ZPIC Attorneys at Oberheiden & McMurrey, LLP

Getting a ZPIC demand letter can be scary and intimidating, especially if you aren’t sure what to do next. Our attorneys have the experience and knowledge you need to help you navigate the ZPIC audit process, and figure out the best way for you and your business to proceed. Don’t risk making a costly mistake attempting to navigate the process alone, or even worse, ignoring the letter you have received.

To learn more about a ZPIC audit and what you can expect – whether or not documentation is requested – you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

Possible Consequences of a ZPIC Audit

ZPIC audits

Coming under the fire of a ZPIC audit can have a variety of consequences for health care providers. Although some of the consequences are more severe than others, a ZPIC audit has every potential to destroy your business forever. To give you a small idea of what might be at risk, the following are some examples of actions that might be taken against a medical practice or provider after the initial probe audit is undertaken by the ZPIC.

Post-Payment Audit

As the name suggests, these ZPIC audits are conducted on Medicare claims that have already been paid out by the government. Unfortunately, in many cases, the ZPICs in charge of conducting these audits tend to apply a strict application of the applicable regulations. Any deviation from them, regardless of how minute or inconsequential, is treated as being suspect. This often results in a failure to comply with every single requirement, significantly increasing the amount the government allegedly overpaid.

Pre-Payment Audit

While a post-payment audit focuses on claims already paid, a pre-payment audit targets claims that a provider is attempting to collect on after providing a service. A pre-payment audit is particularly troublesome for a couple of reasons. Because the services, equipment, and staff time have already been used to provide treatment to the patient, the provider must endure an added layer of payment red tape. The pre-payment audit process can become significantly backlogged to the point where it places a medical practice in jeopardy of not being able to pay its bills on time.

Suspension

ZPICs have the power to initiate actions that are designed to suspend the ability of a medical provider to be reimbursed for the Medicare services rendered. Given the uncertainty of the status of health care insurance, it’s expected that suspensions will continue to grow.

Revocation

Like other aspects of the ZPIC audit process, revocations seem to hinge on the whim of the particular ZPIC that is assigned to a facility. A revocation might occur from slights as simple as being deemed “uncooperative” when a ZPIC was on site, or failing to properly give notice of a move to Medicare .

ZPICs also have the authority to refer medical professionals to the Department of Justice for criminal and civil charges. When a ZPIC audit is getting underway, no one can predict how it will turn out. Seeking out a qualified attorney early in the process provides necessary safeguards.

Contact Experienced ZPIC Audit Attorneys Today

Even if you believe you’ve managed your business exactly as you should, a ZPIC audit can have dire consequences. Because of the costs and the damage to your reputation that can come with an audit, you also risk losing your income and business completely. If you are being audited or you need help appealing, our attorneys have the experience and skills to help you through the process. Contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

Top ZPIC Audit Targets

ZPIC audit targets

As time goes on, the rate of investigations into Medicare fraud is only expected to increase. ZPICs are making an effort to root out all levels of fraud from the obvious to the subtle, and that has some health care providers wondering if they may find themselves targeted in the near future. The best way to protect yourself from an audit is to follow all guidelines to the letter and have a ZPIC lawyer monitor your facility. If you’re wondering what types of facilities might be more at risk, here’s a list of some of the top ZPIC audit targets.

Hospices

Because hospices largely focus on the patient’s needs minute-to-minute, patient treatment protocols can change rapidly. Unfortunately, even if a facility judges that a patient requires a certain procedure or medication, it doesn’t mean Medicare will agree. ZPICs have investigated hospices for what some consider “going too far” with comfort care and other treatments that Medicare deems “unnecessary.”

Home Health Care Companies

ZPICs focus on home health care companies because there is so little public oversight into how they operate. While the vast majority of companies are legitimate and follow the rules, recent reports have indicated an increased rate of fraudulent billing in certain states. This fact increases the risk for ZPIC audits for home health care companies.

Private Practices

Like home health care companies, private physician practices are also responsible for their own individual oversight. The reasons for an increased ZPIC audit rate, unfortunately, aren’t as clear. A small number occur because ZPICs are required to audit a random selection of approximately 120,000 practices, while the rest occur after abusive or fraudulent billing claims.

Diagnostic and Testing Facilities

Diagnostic and testing facilities have an increased rate of ZPIC audits because of the nature of the work they do. All providers are required to justify diagnostic tests, and this includes facilities, too. If a facility cannot provide proof that the patient required a test expressly, ZPICs may view it as abuse of the Medicare system. This includes unnecessary MRIs, blood tests, CAT scans, and ultrasounds.

These are just a few of the most common top ZPIC audit targets. Many other providers have an increased risk too. Always remember that it is possible to be randomly selected for an audit. If you are a provider who has recently received an audit notification, contact a ZPIC lawyer immediately.

Experienced ZPIC Audit Attorneys of Oberheiden & McMurrey, LLP

The truth is, any medical facility is at risk of being audited, sometimes for something as small as a numerical error. Unfortunately, an audit can turn your business upside down and completely destroy everything you have built. If you are at risk of being audited, you have a better chance at a positive outcome if you have qualified and experienced counsel to represent your best interests.

Let us help you and your business through a ZPIC audit in the best way possible. Contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

What Happens in the ZPIC Audit Appeals Process?

ZPIC audit

Each year, hundreds of providers find themselves audited by ZPICs. As these overseers scrutinize account books and procedures to find signs of fraud or Medicare abuse, there is little you can do to prevent an audit other than ensure you’re adhering to guidelines at all times.

If you do find yourself audited, or worse yet, accused of Medicare fraud, most lawyers agree that you should immediately appeal the decision and attempt to fight it. The ZPIC audit appeals process follows this five-step procedure for all appeals.

Redetermination

The first step in a ZPIC appeal is redetermination. This essentially means that a Medicare Administrative Contractor (MAC) will review your information and attempt to determine whether or not there was enough evidence of abuse or fraud on a claim to warrant an audit or action against you. The main goal of this step is to eliminate any potential cognitive bias or assumption that may exist. You have up to 120 days to file a redetermination appeal.

If a second auditor also agrees that there is evidence of Medicare abuse, the appeal may fail at this step. You can then file at the next level, a reconsideration appeal.

Reconsideration

If your redetermination appeal fails, you can request that a Qualified Independent Contractor (QIC) reviews your case through a reconsideration appeal. The QIC cannot have been involved in the redetermination appeal and must view the evidence with fresh eyes.

Within 60 days, the QIC will send a decision in writing. If this step also fails, you move on to an Administrative Law Judge (ALJ) hearing.

Administrative Law Judge (ALJ)

The ALJ hearing gives you the opportunity to explain your case to yet another individual who wasn’t involved in the original two appeal levels. This step allows you to explain the evidence in person. However, not every provider is entitled to an ALJ hearing; the total of the claim must be over $160 to qualify.

Like the QIC, the ALJ will make a decision independently and provide it in writing. If it fails, the next step is to take your appeal to the Medicare Appeals Council (MAC).

Medicare Appeals Council (MAC)

If you refute the ALJ’s decision, he or she will provide you with instructions for contacting the MAC. You can apply to the MAC for a full review, in writing, at the address provided to you by the ALJ. If you are unsatisfied with the MAC’s decision, or if they fail to provide a response within a timely manner, you may be able to bring your case to the Federal District Court (FDC).

Federal District Court

Most Medicare audit appeals never reach the Federal District Court; only cases with a claim amount for over $1,560 have the ability to access the FDC. If you qualify, and you assert that you do not agree with the MAC’s decision, the MAC will provide you with the information needed to schedule your day in court. It is highly recommended that you do not approach this highest level of appeal without a lawyer by your side. If you’ve reached the fifth level of appeal, consult a Medicare audit lawyer immediately.

In any event, the appeals process of an audit can be just as overwhelming as the audit itself. Contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

What to Expect from ZPIC Audit Protocol

ZPIC audits

Audit candidate selection is rarely a result of random chance. They base their choice on statistical anomalies or inconsistencies in the accused health care provider’s records and activities. A ZPIC audit may also result from employee complaints or referrals by government and law enforcement entities. Although ZPIC has a high amount of discretion in their investigation, they must still follow certain protocols.

ZPIC Timeline

There is a typical timeline that comes with an audit. Although the order may vary depending on ZPIC’s discretion, there is always an initial inspection and follow up requests for additional information.

ZPIC will request medical records and all business-related documentation which may include patient reports. The provider must fulfill these requests within 15 days. ZPIC can request additional records and clarifications as many times as they see fit. There is no limit to how many requests they can make or on how long they may continue their investigation.

Then, an initial visit by ZPIC inspectors will take place. These visits may be unannounced and law enforcement officials may accompany ZPIC if they deem it necessary. They may also interview employees during their visit. It’s recommended to provide legal counsel during these interviews. The health care provider must arrange this before an audit takes place. ZPIC may require the case to escalate to other law enforcement agencies.

Statistical Analysis and Extrapolation

Although it might seem complicated, a ZPIC audit can include statistical analysis and extrapolation techniques as part of their investigation. ZPIC may do this if they find a “sustained or high level of payment error” in the health care provider’s records. ZPIC does not clearly define this “payment error” due to their broad scope and the discretion available for their investigations. This broad scope can be used by the defendant since it is subjective.

ZPIC must provide clear explanations to the defendant if they decide to use statistical extrapolations in their investigation. They must also disclose why the review is happening, the time frame under review, and the appropriate medical record and other documentation to support ZPIC’s claims. They must also reveal the location where the review will take place, explain how they will release the results to the public and the potential methods of financial reclamation ZPIC may impose on the provider.

Because the many facets of a ZPIC audit can be complicated, including the protocol that ZPIC themselves must follow throughout the process, you can’t afford to navigate the process alone. An experienced attorney can help you with the ZPIC audit while you focus on managing your business.

ZPIC Audit Attorneys with Experience at Oberheiden & McMurrey

Although there is certain protocol that a ZPIC audit must follow, it doesn’t always happen. This is just one of the reasons you need an experienced attorney on your side to make sure you retain your rights throughout the process. If you are being audited or need help with an appeal, don’t panic. Contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

What Happens After a ZPIC Audit?

ZPIC audits

If you are facing a ZPIC audit or you have gone through one, you might be wondering what happens afterward. In many cases the results are almost guaranteed to result in negative repercussions for the health care provider. However, there is also a possibility that you come out ahead. Here are a few of the different outcomes you can expect to face, depending on your situation, after a ZPIC audit.

Pre-Payment Review

The most likely result of a ZPIC audit is ZPIC enforcing a pre-payment review system for an indeterminate amount of time. This means they will review and approve a certain percent of the provider’s Medicare claims. The error rate in payments that ZPIC finds in their investigation determines the percentage of current and future cases they will review. Pre-payment reviews of 100% result in ZPIC reviewing every Medicare claim and withholding the provider’s claims until the audit concludes.

Monetary Compensation

ZPIC can reclaim cases that resulted in overpayments. How ZPIC does this is at their discretion, based on the severity of their charges against the provider. They can go through each case or impose a fee based on extrapolation of previous overpayments.

In the Case of Fraud

If ZPIC suspects any fraud after the audit, they must report the health provider to law enforcement agencies. They only need to have the slightest evidence of fraud to report the health care provider regardless of the amount in question. Law agencies involved can include the Office of Inspector General. There is a 90-day time frame where the Office of Inspector General must either reject the case or escalate it to the Department of Justice.

Blacklist or Revocation of License

The worst-case scenario happens when ZPIC blacklists the health provider from Medicare. The provider must cooperate and oblige to ZPIC’s requests. If the provider is uncooperative during ZPIC’s investigations or attempts to circumvent this mandate then they may have their license revoked.

The outcome of a ZPIC audit depends on what they find in their investigation. The defendant can challenge these results to an extent since ZPIC has a large amount of discretion and freedom to enact whatever repercussions they think are suitable so long as they have sufficient evidence and reason. Depending on the case, there could also be criminal charges and jail time.

Experienced ZPIC Audit Attorneys at Oberheiden & McMurrey

As you can see, a ZPIC audit can have devastating effects on your business, from lost income to penalties and even the possibility of losing your business. At Oberheiden & McMurrey we understand that you have a lot on the line. Don’t risk the welfare of your business by putting your case in the wrong hands, or attempting to navigate a ZPIC audit alone.

Make sure you have the right legal team on your side to help you through it. If you are being audited or need help with an appeal, contact our attorneys at (888) 727-5159 or complete our online contact form today.