Is Your Practice Being Audited by a ZPIC? Did You Know it Can Lead to an OIG Exclusion?

Zone Program Integrity Contractors (ZPICs) are among the most aggressive program integrity entities employed by the Centers for Medicare and Medicaid Services (CMS).  As most healthcare providers are aware, ZPICs regularly place physician practices on prepayment review and sometimes conduct post payment audits of previously paid claims.  However, did you know that ZPICs are also supposed to play a role when it comes to “exclusions”

According to Sec. of the Medicare Program Integrity Manual (MPIM) reflects, ZPICs are actually REQUIRED by CMS to review and evaluate cases to determine if they warrant exclusion action.  And if in its estimation exclusion is warranted, they must make a recommendation to the Office of Inspector General (OIG) for consideration.

Section 2.2 lists a number of examples of the types of cases that would be suitable for the ZPIC to make an exclusion recommendation.  Some of them, such as convictions of program related offenses under (§1128(a)) and convictions related to patient abuse or the sale and use of drugs (§1128(b) are common sense and would likely have already resulted in the initiation of an exclusion action, but a number of others may surprise you.  Below you will find a partial list:
  • Providers who have a pattern of adverse QIO, AC, or MAC findings.
  • Providers whose claims must be reviewed continually and are subsequently denied because of repeated instances of overutilization.
  • Providers who have been the subject of previous cases that were not accepted for prosecution because of the low dollar value.
  • Providers who furnish or cause to be furnished items or services that are substantially in excess of the beneficiary’s needs or are of a quality that does not meet professionally recognized standards of health care (whether or not eligible for benefits under Medicare, Medicaid, title V or title XX).
  • Providers who are the subject of prepayment review for an extended period of time (longer than 6 months) who have not corrected their pattern of practice after receiving educational/warning letters.
ZPICs that make exclusion recommendations are required to consider a number of factors and are supposed to consider alternatives in an effort to change the provider’s conduct.  And, of course, the final authority to exclude a provider from participation in Federal health benefits programs lies with the OIG.  But it is important for you to keep in mind that this is yet another risk area your practice may face in the event of a ZPIC audit. 

Unfortunately, this is only one of the additional risks that your practice may face.  For additional information on ZPIC audits, we recommend you review the recent article by Robert W. Liles entitled “UPIC / ZPIC Referrals to State Licensure Boards, Professional Societies, State Surveyors, QIOs and to the OIG for Exclusion Consideration.”  it provides a nice preview on inter-agency referrals of complaints by ZPICs.  Be reached at: (202) 298-8750.

About the AuthorCo-Founder, Exclusion Screening
Paul Weidenfeld is a long time health care lawyer who has specialized in litigation arising out or, or relating to healthcare fraud and the False Claims Act. A former federal prosecutor and National Health Care Fraud Coordinator for the Department of Justice, Paul is a frequent speaker who has earned recognition both as a Federal Prosecutor and as a member of the private bar.  Paul is also a co-founder of 
Exclusion Screening, LLC, a company that offers providers a simple, cost effective way to meet their exclusion screening obligations.

Auditing a Compliance Hotline Provider

Compliance Hotline Auditing

Under the Affordable Care Act, medical service providers must establish compliance programs to enroll in the Federal health care programs. HHS has neither issued regulations on the core requirements of these compliance plans nor set a date for mandatory compliance. Providers, however, should consider adopting a compliance hotline program prior to the mandate not only because a requirement is imminent, but also to prevent fraud and demonstrate good faith.

Elements of an Effective Compliance Program

One of the seven elements of an effective compliance program is developing open lines of communication. CMS recommends that lines of communication run in multiple directions and include a process for anonymous reporting to provide an outlet for employees who may fear retaliation.

Many providers utilize an outside vendor to facilitate anonymous reporting. If you elect to use an outside vendor, you should choose a well-managed hotline that is focused on the health care sector. In addition, your organization should periodically audit the hotline to measure its effectiveness.

Considerations of a Compliance Hotline Auditing

When auditing a compliance hotline vendor you should consider (a) does the hotline have established policies and procedures, (b) how is the hotline managed, and (c) does the hotline meet its goals.

Some questions you might use to review the hotline’s management, operation, and effectiveness include:

  1. Does the hotline follow its established policies and procedures?
  2. Do the policies discuss how to document and follow-up calls?
  3. Does the hotline act on calls and/or emails promptly?
  4. Does the hotline follow up with callers who provide contact information?
  5. Are hotline administrators properly trained to answer calls and ask appropriate questions?
  6. Does your department tasked with reviewing hotline reports receive reports in a timely manner?
  7. Are the reports provided by the hotline detailed enough to allow your organization to follow up and investigate?
  8. Is caller anonymity being protected?
  9. Are hotline files protected?

In addition, you should also evaluate your office’s internal use of the hotline by considering the questions below.

  1. Are employees aware and reminded that the hotline is available?
  2. Does the department tasked with handling reports follow up properly?
  3. Are your employees using the hotline?
  4. Do employees seem confident about the effectiveness of the hotline?
  5. Does the department handling hotline reports file and protect reports appropriately?

If you answered “no,” to one or more of these questions, it may be time to consider a new vendor. Call Exclusion Screening, LLC today to discuss our ComplianceHotline, which is staffed by Certified Medical Compliance Officers, today at 1-800-294-0952.

Compliance Hotline Auditing

Ashley Hudson, Associate Attorney at Liles Parker, LLP and former Chief Operating Officer for Exclusion Screening, LLC, is the author of this article.