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A Peek at ZPIC/PSC Benefit Integrity Unit Complaint & Referral Process. Amy Miller-Bowman PSC Midwest Integrity Center. Zone Program Integrity Contractors (ZPICs). MT. WA. ME. ND. VT. Zone 2: AdvanceMed . NH. OR. NY. ID. MN. MA. SD. WI. MI. Zone 6. WY. RI.

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a peek at zpic psc benefit integrity unit complaint referral process

A Peek at ZPIC/PSC Benefit Integrity Unit Complaint & Referral Process

Amy Miller-Bowman

PSC Midwest Integrity Center

zone program integrity contractors zpics
Zone Program Integrity Contractors (ZPICs)

MT

WA

ME

ND

VT

Zone 2:

AdvanceMed

NH

OR

NY

ID

MN

MA

SD

WI

MI

Zone6

WY

RI

IA

CT

PA

Zone 1:

SGS*

Zone 3**

NE

OH

NJ

IN

DE

WV

NV

UT

IL

VA

CO

MD

KS

KY

MO

DC

NM

NC

TN

AR

CA

Zone 5:

AdvanceMed

SC

OK

Zone 4 –

Health Integrity

AZ

AL

GA

MS

TX

Zone 2

LA

Zone 7: SGS

AK

PR

HI

Zone 1: SGS*

*Other territories of Zone 1 include American Samoa, Northern Marianas Islands and Guam

**Cahaba received the award for Zone 3, but it is currently on a stop-work order due to contract protest

cms pim requirements
CMS PIM Requirements
  • PSC and ZPIC Benefit Integrity (BI) Units:
    • Must use variety of techniques, both proactive and reactive, to address any potentially fraudulent billing practices
  • Program Integrity Manual (PIM) requires all investigations be:
    • Unique
    • Tailored to specific circumstances
cms pim requirements4
CMS PIM Requirements
  • ZPIC BI units
    • Investigations and cases with greatest program impact/and or urgency must be given highest priority.
    • Allegations or cases having greatest program impact involve:
      • Patient abuse or harm
      • Multi-state fraud
      • High-dollar amounts of potential overpayment
      • Likelihood for increase in amount of fraud or enlargement of pattern
complaint screening
Complaint Screening
  • After receipt, complaint is screened
    • Screening process includes a query for past complaints (both open and closed) regarding the provider
    • Current provider information includes:
      • National Provider Identification (NPI) number
      • Provider address
      • Chain information
  • After screening, complaint is assigned to an investigator.
investigation steps
Investigation Steps

Review small sample of claims recently submitted

May need to request medical documentation or other evidence that would validate or cast doubt on claim validity

investigation steps7
Investigation Steps
  • Conduct telephone interviews of small number of beneficiaries to determine if:
    • If other false claims appear to exist

OR

    • If this was a one-time occurrence
investigation steps8
Investigation Steps
  • Look for past PSC, ZPIC, or MR unit contacts concerning comparable violations
  • Check provider correspondence files for:
    • Educational/warning letters
    • Contact reports that relate to similar complaints
  • Review complaint file
  • Discuss suspicions with MR and audit staff, as appropriate
investigation steps9
Investigation Steps

Perform data analysis

Review telephone calls or written questionnaires to physicians, confirming need for home health services or DME

Perform random validation checks of physician licensure

Review original CMNs

investigation steps10
Investigation Steps
  • Perform analysis of procedures and items:
    • High frequency/high cost
    • High frequency/low cost
    • Low frequency/low cost
    • Low frequency/high cost
investigation steps11
Investigation Steps
  • Perform analysis of local patterns/trends of practice/billing against national and regional trends:
    • Begin with top 30 national procedures for focused MR and other kinds of analysis that help identify cases of fraudulent billings
  • Initiate other analysis enhancements to authenticate proper payments
  • Perform compilation of documentation:
    • Medical records
    • Cost reports
investigation steps12
Investigation Steps
  • Using internal data, PSC and ZPIC BI units may determine:
    • Type of provider involved in allegation
    • Perpetrator (if an employee of provider)
    • Type of services involved in allegation
investigation steps13
Investigation Steps
  • Examples of areas to be researched:
    • Places of service
    • Claims activity (including assigned and non-assigned payment data in the area of the fraud complaint)
    • Existence of statistical reports generated for the Provider Audit List (PAL) or other MR reports, to establish if this provider's practice is exceeding the norms established by their peer group (review the provider practice profile)
investigation steps14
Investigation Steps
  • Review all available material
  • Decide if it is reasonable to spend additional investigative resources
  • If any documentation is available on prior complaints, obtain:
    • Appropriate Form CMS-1490s and/or 1500s
    • UB-92s
    • Electronic claims, and/or attachments
discussion with oig oi
Discussion with OIG/OI

If pattern appears, discuss with OIG/OI at onset of investigation

At the end of all investigations, discuss investigation facts with OIG/OI

Obtain OIG’s recommendation on whether or not investigation should be further developed for possible case referral to OIG/OI

final steps
Final Steps
  • If investigations do not result in a case, the PSC and the ZPIC BI Units take all appropriate action:
    • To prevent any further payment of inappropriate claims
    • To recover any overpayments that may have been made
and the security door closes
And the Security Door Closes…
  • As ZPIC/PSC contractors, we empathize how frustrating this can be to the SMP and the beneficiary.

Due to contractual obligations and legal requirements, sometimes information cannot flow both ways.

alice s story
Alice’s Story
  • Alice lives in Iowa and is 87 years old.
  • Alice has been in hospice care for 8 months.
  • Alice’s hospice company recently called Alice’s daughter to report more than 1200 Oxycotin pills were missing.
  • Hospice company believes a hospice nurse has been stealing the medication.
alice s story19
Alice’s Story
  • Alice’s daughter also had concerns about Alice’s recent recertification for hospice from the physician:
    • Face-to-face visit
    • No vitals taken
    • Lasted 5 minutes
  • Alice’s daughter told the news about the missing medication and the hospice recertification to her own daughter, who works for a PSC.
alice s story20
Alice’s Story
  • ZPIC contractor informed the MFCU.
  • Alice’s granddaughter documented and reported all information to the ZPIC contractor.
and the security door closes21
And the Security Door Closes…
  • As a contractor, Alice’s granddaughter understands she has no guarantee she will ever learn results from Alice’s reported case.