Ask the payment expert: explaining the effect of ZPICs on long-term care providers

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Ask the payment expert
Ask the payment expert
What are ZPICs and should we be worried about them?

ZPICs are the newest method that the Centers for Medicare & Medicaid Services is developing to scrutinize facilities for fraud and abuse.

ZPICs are Zone Program Integrity Contractors and they are rolling out across the country. They will be looking at Part A and Part B providers, including skilled nursing facilities, and one of the issues that may be targeted in nursing facilities is the large percentage of residents with high resource utilization groups. These Benefit Integrity (BI) reviews are another way that CMS has to look at Medicare claims.

ZPICs, along with Recovery Audit Contractors (RACs) and the recent increase in medical review activity, place facilities at increased risk for claim reviews.

Facilities need to have processes

in place to ensure they are billing appropriately.  Internally, they should be monitoring their systems for Medicare to ensure appropriateness of care. This should include monitoring RUGs levels, ADL scores and completing a triple-check process prior to submitting claims for payment.

Externally, each facility should have a Medicare assessment in its corporate compliance plan. This should include a review of reasonable and necessary services and all Medicare requirements.

You might think you know what is best for your resident; reviewers might not see it the same way. An objective eye can help you see how the claim may be interpreted. Get any assistance you need to minimize your risk.

If you have good systems in place, if you are giving clinically appropriate care and if you follow the Medicare rules, you shouldn't have to worry if you do have a review. Be it a Medical Review, a RAC review or a ZPIC review, following the rules is the way to go.