Fw: ZPIC audit Complaint to SBA
ORTHOTICS BILLER
Description
Collection
Title:
Fw: ZPIC audit Complaint to SBA
Creator:
ORTHOTICS BILLER
Date:
8/23/2012
Text:
I have registered a complaint with the SBA in regards to our status in a ZPIC audit. I know many practices are dealing with this right now and hope that maybe this will assist us all if we register complaints about the system. Our complaint was submitted as stated below.
We are a small privately owned Orthotics and Prosthetics
practice who have become caught up in the ZPIC (Pre-payment) Audits by CMS and
its contracted auditors. We have several
concerns that seem to make “working our way out” seem virtually
impossible.
1) Our first and very valid concern is the
documentation.
A) The LCD’s are very heavily worded and amended so
frequently that it is difficult to know what is expected of you as far as
documentation. It almost always is open
for interpretation. What we believe is
the correct way or what a particular seminar may have taught us, may very well
be simply that individual’s interpretation and in reality may not meet the
criteria of CMS or its many contracted auditors.
B) The next portion of this concern reaches out to
the Physician’s we are dependent upon for documentation that prevents payment
to us for our services. The physician
can sign off and state that a patient is Diabetic, and qualifies for diabetic
shoes because he has callus formation, on the CMS Certifying Statement form
required for payment on diabetic shoes. We then have to have progress notes to support the same information
provided by the doctor signing off, so we request these records, but the doctor
has not made written note of the callus formation in the record so we do not
have the proper documentation. This is
impossible, unless we are there with each physician for each patient, we cannot
monitor their record keeping, and who gives us as O&P providers this
authority. CMS is refusing to pay us
for another’s actions. Sending the
letter that CMS provides to the Physician’s isn’t helpful as the letter like
most requirements is open to varied interpretations. In addition, we are reliant
on the Physician’s for referrals and they on us for our knowledge in Orthotics
and Prosthetics yet CMS is pitting us against each other in the battle of
documentation and the expectations that the Physician’s should not only do
their jobs but also do ours, and tying our hands to assist in our areas of
expertise.
2) We have been in audit for almost one year!!! We
are in survival mode at this point. We
had errors and made improvements but none of these things were direct
fraud. We have paid for the items
provided to the patients and provided the services and yet we have not received
payment. As a contractor we are expected
to continue to provide services to Medicare patients and continue to bill
claims, but every claim goes into ZPIC, however if we don’t then that shows
varied billing patterns that triggers yet another CMS red flag. The paperwork always has a flaw of some sort
( it is impossible to comply when what you are complying with changes so
frequently), and we end up going through every stage of appeal, which we are
paying a contracting company to handle, and financially it is not logical to
contest most claims under $500 dollars. That is a lot of claims that will never see payment although the
Physician prescribed them and we provided them, and the patient accepted
them. These claims are not even the
most alarming, as the prosthetic claims that are tied up in this audit could
support our small practice for the last year. We are playing a game we can’t win with rules that change so frequently
there is no way to play fair.
3) The auditing groups are paid on monies that they
recoup, yet they are the ones to review our submitted support documentation for
compliance. Why would they see any
paperwork as compliant and loose the funds they are dependent on for financial
gain? The logical answer is that they wouldn’t. This seems like a conflict of
interest.
4) We are not allowed to contact the auditing group. We are only in contact by fax with a company
that will not respond to us with anything more than a request for records and
repeated denials of substantial paperwork forcing us to secure an outside
source to handle the audit because they have professional contacts with the
auditing groups. This is a very costly
solution to attempt to meet the requirements of CMS, notably when there is no
payment for the products or services already paid for by our practice and provided
to the patient per the physician order. Are these auditing groups supervised? Do they have rules and criteria? We are simply told our claims have to improve to be taken off of the
prepayment audit. Improvement has
happened, but we remain on audit with only very vague reasons for nonpayment.
In closing, this is enough to put any standard private
practice out of business. The expenses we
are being forced to incur are extreme, and all of this comes without a promise
of any future payments. We have no
example of a perfect claim to file, and ever-changing rules, with 100% of our Medicare
claims being sent to ZPIC. The
prevention of fraud to the system is understandable and justified but the
system should not be fraudulently withholding payments from the suppliers
either.
Brandy Carpenter
Greeneville O&P
We are a small privately owned Orthotics and Prosthetics
practice who have become caught up in the ZPIC (Pre-payment) Audits by CMS and
its contracted auditors. We have several
concerns that seem to make “working our way out” seem virtually
impossible.
1) Our first and very valid concern is the
documentation.
A) The LCD’s are very heavily worded and amended so
frequently that it is difficult to know what is expected of you as far as
documentation. It almost always is open
for interpretation. What we believe is
the correct way or what a particular seminar may have taught us, may very well
be simply that individual’s interpretation and in reality may not meet the
criteria of CMS or its many contracted auditors.
B) The next portion of this concern reaches out to
the Physician’s we are dependent upon for documentation that prevents payment
to us for our services. The physician
can sign off and state that a patient is Diabetic, and qualifies for diabetic
shoes because he has callus formation, on the CMS Certifying Statement form
required for payment on diabetic shoes. We then have to have progress notes to support the same information
provided by the doctor signing off, so we request these records, but the doctor
has not made written note of the callus formation in the record so we do not
have the proper documentation. This is
impossible, unless we are there with each physician for each patient, we cannot
monitor their record keeping, and who gives us as O&P providers this
authority. CMS is refusing to pay us
for another’s actions. Sending the
letter that CMS provides to the Physician’s isn’t helpful as the letter like
most requirements is open to varied interpretations. In addition, we are reliant
on the Physician’s for referrals and they on us for our knowledge in Orthotics
and Prosthetics yet CMS is pitting us against each other in the battle of
documentation and the expectations that the Physician’s should not only do
their jobs but also do ours, and tying our hands to assist in our areas of
expertise.
2) We have been in audit for almost one year!!! We
are in survival mode at this point. We
had errors and made improvements but none of these things were direct
fraud. We have paid for the items
provided to the patients and provided the services and yet we have not received
payment. As a contractor we are expected
to continue to provide services to Medicare patients and continue to bill
claims, but every claim goes into ZPIC, however if we don’t then that shows
varied billing patterns that triggers yet another CMS red flag. The paperwork always has a flaw of some sort
( it is impossible to comply when what you are complying with changes so
frequently), and we end up going through every stage of appeal, which we are
paying a contracting company to handle, and financially it is not logical to
contest most claims under $500 dollars. That is a lot of claims that will never see payment although the
Physician prescribed them and we provided them, and the patient accepted
them. These claims are not even the
most alarming, as the prosthetic claims that are tied up in this audit could
support our small practice for the last year. We are playing a game we can’t win with rules that change so frequently
there is no way to play fair.
3) The auditing groups are paid on monies that they
recoup, yet they are the ones to review our submitted support documentation for
compliance. Why would they see any
paperwork as compliant and loose the funds they are dependent on for financial
gain? The logical answer is that they wouldn’t. This seems like a conflict of
interest.
4) We are not allowed to contact the auditing group. We are only in contact by fax with a company
that will not respond to us with anything more than a request for records and
repeated denials of substantial paperwork forcing us to secure an outside
source to handle the audit because they have professional contacts with the
auditing groups. This is a very costly
solution to attempt to meet the requirements of CMS, notably when there is no
payment for the products or services already paid for by our practice and provided
to the patient per the physician order. Are these auditing groups supervised? Do they have rules and criteria? We are simply told our claims have to improve to be taken off of the
prepayment audit. Improvement has
happened, but we remain on audit with only very vague reasons for nonpayment.
In closing, this is enough to put any standard private
practice out of business. The expenses we
are being forced to incur are extreme, and all of this comes without a promise
of any future payments. We have no
example of a perfect claim to file, and ever-changing rules, with 100% of our Medicare
claims being sent to ZPIC. The
prevention of fraud to the system is understandable and justified but the
system should not be fraudulently withholding payments from the suppliers
either.
Brandy Carpenter
Greeneville O&P
Citation
ORTHOTICS BILLER, “Fw: ZPIC audit Complaint to SBA,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/234232.
