zpic audit

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Have You Checked Your Addresses on File with CMS/Medicare Recently?

Do you remember the last time you checked all four of the addresses you should have on file for any individual or any group/company Medicare number you may have?  The consequences of not updating these addresses can be severe.  In addition to your mailing (or correspondence address), and your billing address, you also should have a physical address that is complete, accurate and timely.  The telephone number for that physical address should also be in the system.  You must ensure that not only is the street address accurate, but also that any suite, office or apartment number on it is accurate.  Check the zip code, too, just to be certain you did not transpose digits when you entered it.

Auditors, surveyors, inspectors and investigators are often sent out by Medicare and its contractors, including the Medicare Administrative Contractors (or “MACs”) and the Zone Program Integrity Contractors (or “ZPICs”), to the physical address on file.  This is done as a fraud prevention tool to make sure that medical practices, durable medical equipment companies (DMEs), home health agencies (HHAs), and other businesses that receive payments from Medicare are legitimate and are actually operating.

Termination of Medicare Billing Privileges Often Results From Incorrect Addresses.

Site inspections and audits are also conducted by sending auditors on short notice or no notice to the physical address on file.  If your physical address is incomplete (e.g., no suite number) or wrong (e.g., incorrect street address) or is not up to date (e.g., you moved and forgot to update it), the consequences could be severe.  What we have seen most often recently is an action that terminates the Medicare billing privileges.  The provider then is not allowed to reapply for a period of two (2) years from the date of termination.

Update All of Your Addresses with Medicare Immediately.

I urge you to personally and immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information to check it.  If your address is incorrect or incomplete, immediately submit a correction or have your administrator practice manager do this.

If anything is incorrect, including an incorrect or incomplete name for your medical group, corporation or business, immediately have this corrected, as well.  Everything should be consistent, and all of your state licenses and corporation/company information on file with your Secretary of State should also contain the same information, as well.

What to Do if You Receive a Notice of Termination of Your Medicare Provider Number.

Have you received a notice of termination of your Medicare provider number? Medicare has been revoking the Medicare billing privileges of many different Medicare providers including physicians, medical groups, home health agencies (HHAs), pharmacies, and durable medical equipment (DME) providers, based on returned mail sent to old addresses which have not been updated or based on inspection team site visits to old, incorrect addresses.

Often the termination is retroactive to an earlier date when the change or move may have been determined to have occurred. Even if the mailing address is correct or was changed, the physical address of the business must have been updated, as well. It is usually an incorrect or old physical address which causes this to occur.

The effect of this termination includes:

1. You are prohibited from reapplying to Medicare for at least two (2) years.

2. You may have to pay back any monies received from the Medicare Program since the effective date of the termination (often many months prior to the notification letter).

3. Other auditing agents may be notified such as the Medicare Zone Program Integrity Contractors (ZPIC) and the state Medicare Fraud Control Unit (MFCU).

4. You may no longer contract with Medicare or anyone who does.

5. You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.

6. You may and probably will be terminated from skilled nursing facilities (SNFs) and home health agencies (HHAs) with which you have contracts.

7. You may and probably will have your clinical privileges terminated by hospitals or ambulatory surgical centers (ASCs) where you have them.

What you should not do includes:

1. Don’t bother to write letters or start e-mailing anyone, including CMS or the Medicare Administrative Contractor (or MAC) (previously called the “carrier” or “fiscal intermediary”).

2. Don’t bother to call the Centers for Medicare & Medicaid Services (CMS) or the MAC.

3. Don’t bother to file a new CMS Form 855 (application) or a CMS Form 855C (change).

4. Don’t bother to start communicating with CMS or the MAC about your situation and what you need to do about it.

5. Don’t bother to complete and file the short, one-page Corrective Action Plan (CAP) form that is on the CMS or Carrier/MAC website (unless you are close to the deadline and don’t have representation; then you must.)

What we recommend is:

1. Immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information. Then update or correct any incorrect information on you or your company, if you can. Print out the information as it existed before and print out the information after you have corrected it. (Note: Medicare will act shortly after the letter to you to terminate your access to this, so it may be too late).

2. Hire an experienced health attorney immediately to assist you in putting together and submitting a comprehensive Corrective Action Plan (CAP), a Request for Reconsideration (RFR) and a request for an Appeal Hearing.

3. Note that there is a thirty (30) day deadline for submitting the CAP and a sixty (60) day deadline for requesting an appeal hearing. Do not miss these.

4. Implement formal, written internal policies and procedures to prevent a recurrence of the type of error, oversight or event that caused the termination.  Train your management and staff on these.

The CAP should address every element of the applicable conditions of participation (COP) contained in the Code of Federal Regulations (CFR). It should include and be supported by all relevant documents, including but not limited to:

1. Documents showing how the error occurred or past efforts to comply.

2. Surety bond guarantees and documents (where required).

3. Insurance coverage documents showing current coverage (general liability, professional liability, vehicle/auto liability).

4. Current licenses and permits.

5. Certificates of good standing and latest annual reports for any corporation or limited liability company.

6. Print-outs from PECOS/NPPES Registry discussed above.

7. Accident reports, insurance claims, police reports, fire reports or other documentation showing why a relocation was required (if this was an issue).

8. Certificates of compliance training for you and your staff, if available.

9. Copies of policies and procedures that you have adopted to keep there from being a recurrence of the situation that led to the termination.

10. An authorization form for your consultant or attorney to represent you in the matter.

All copies should be clear, legible, complete, straight, no corners cut off and no handwriting on them, to the greatest extent possible.

Organize, Label and Index Professionally.

Everything should be professionally assembled, typed, indexed and labeled. It should include a table of contents or an index. Number every page. It should be submitted to the MAC (or the agency/address given in the termination letter) by two (2) reliable means that document both sending and receipt. Keep copies of everything, including postal receipts, airbills, Federal Express labels, courier receipts, etc. It must be received at the address given in the termination letter you received (usually MAC) by the deadline given above. Keep copies of online tracking reports and return receipts.

In most instances, should you show a legitimate reason for the error, show you are currently in compliance, and show what remedial measures you have taken to keep there from being a repeat, the MAC will accept your corrective action plan (CAP) and will reinstate your Medicare number, as things stand currently.

Don’t Wait Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The lawyers of The Health Law Firm routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicare and Medicaid investigations, audits and recovery actions.  They also represent them in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge.  Attorneys of The Health Law Firm represent health providers in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.

Call now at (407) 331-6620 or (850) 439-1001 or visit our website www.TheHealthLawFirm.com.

About the Author:  George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

Disclaimer:  Please note this article is for general education and information purposes only and does not constitute legal advice or solicitation for clients.  Our opinions stated herein are just that, our opinion.