Recoupment and Payor Appeals — ZPIC and Express Script Audits

Recoupment and Payor Appeals — ZPIC and Express Script Audits

Almost every company that works with Medicare and Medicaid will at some point face a ZPIC audit that is performed by a CMS contractor such as Express Scripts, Qlarant or Cotiviti. These audits are investigations into fraud, waste and abuse.

These investigations focus on fraud, waste, and abuse within the company pertaining to health care services and related activities. These investigations are not random; many audits are instigated based on a suspicion that fraud has occurred, with the intent of identifying and proving those suspicions. The goal is to separate fraud from error. When a provider receives an audit notification, they need experienced legal counsel to help them successfully navigate the process while minimizing impact on the organization.

Elliott Sauter attorneys have
handled audits for:

  • Home health care companies
  • Durable medical equipment companies
  • Pharmacies
  • Laboratories
    • Genetic testing
    • CGx testing
    • PGx testing
    • COVID testing
  • Hospices
  • Medical practices

We work within your organization to establish specific parameters for an internal investigation. This includes researching billing data, medical records and conducting employee interviews.
We have extensive experience in data mining and analysis, two invaluable tools in assisting a provider’s response to pre- and post-payment audits.

An adverse audit result can lead to significant repayments to the government and possible program suspension. In extreme circumstances, the Office of Inspector General (OIG) might step in for further investigation.

As a firm of former federal prosecutors, Elliott Sauter brings years of experience towards protecting your organization from further legal action in the event of an audit.

Protect Yourself in a ZPIC Audit

ZPIC audits often rely on beneficiary complaints and referrals to the Office of Inspector General hotline in determining the need for investigation. ZPICs also heavily utilize data analysis and statistical techniques.

Providers and organizations are usually selected for auditing based on the following:

Employees or beneficiaries make complaints to the Office of Inspector General
Detection of patient care anomalies (in comparison to other local providers)
Data Outliers
High frequency of certain services and billing trends

Here are a few examples:

A Home Health Agency might have multiple patients that are continuously recertified. While there is sometimes a medical reason for multiple recertifications of a patient, the ZPIC needs to make sure the organization did not keep a patient on service longer than necessary. The agency may receive a ZPIC audit requesting records to ensure that there is medical necessity for the recertifications.

Similarly, anomalous dispensing patterns (for example, an unusually high volume of “high cost, low value” pharmaceuticals) may provoke an audit to determine medical necessity.

How does the ZPIC Audit process work?


Request for Additional Documentation

To begin their analysis, the ZPIC will often request the following documentation from providers or organizations:

  • Medical records and documentation
  • All billing information

The ZPIC will generally request a sample size of 30 to 40 records and will give an initial 14 day time frame to provide them. Providers will then need to perform an in-depth examination of the requested records to try to determine what issues may exist.

Providers should immediately contact an attorney with experience in responding to ZPIC audits to aid them in their response. As former federal prosecutors, we have worked on ZPIC audits from the perspective of the government, and can often tell from the request the focus of the ZPIC audit. By understanding the underlying issues that have triggered the auditing process, an organization can increase their chances of successfully passing the audit and minimizing its impact.


Unannounced Visits

Investigators will sometimes show up unannounced and hand deliver a request for the necessary documents and deliverables. Providers should immediately contact their attorney if this occurs, but should also comply with the ZPIC requests as they wait for their attorney to take action. ZPICs will often request to interview management and staff.

For this reason, among several others, your organization should have adequate training and compliance programs in place to ensure the integrity of your practice and to be thoroughly prepared in the event of an audit or similar event.


ZPIC Auditors Make Recommendations to the CMS and OIG

The ZPIC auditors make recommendations to CMS and can refer cases to the Office of the Inspector General (OIG). The ZPIC can recommend that the provider be suspended from receiving Medicare payments based on their findings.

When faced with a suspension, many providers are forced to close their business. If a provider is turned over to the OIG for investigation, criminal charges could be brought against them.
It is imperative that providers retain knowledgeable legal counsel to help them through any ZPIC involvement. Many providers retain counsel to do periodic internal audits to lessen the chance of being audited by the ZPIC.

At Elliott Sauter, we understand the data analytics used by ZPIC and can help providers audit their files to determine if abnormalities exist. We have experience helping providers develop compliance programs that prevent future problems and address any current deficiencies.

Responding To Recoupments and ZPIC Audits

We recommend that providers remain attentive and calm during the auditing process. It is indeed a high-stress situation and can create an unhealthy working environment for some. This can lead to providers rushing through their end of the auditing process. That means overlooking documentation in order to meet deadlines. This mistake can be costly to the provider as documentation needs to be complete. Incomplete documentation and deliverables will only add more reason to suspect fraud. Additionally, providers and organizations should not be so quick to simply accept the results of an audit: it’s wise to thoroughly review the audit results to investigate the possibility of an appeal. This can be handled by an experienced attorney who understands common auditing mistakes.


Elliott Sauter, PLLC

Our former federal prosecutors and healthcare attorneys are ready to assist.

Call us or complete the form with your case information to speak with an attorney today.


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