Zpic Auditing

What is a ZPIC Audit?

The purpose of ZPIC audits is to investigate allegations of fraud and abuse in healthcare. There are typically three red flags for a healthcare facility to be targeted for a ZPIC review. First is data analytics: something’s outlying for the agency consistently; second is complaints, whether they are from the beneficiary or any staff member; and last is a referral from the MAC because of not improving in a targeted review.

The seriousness of a ZPIC Audit

The ZPIC health audit is a very serious audit. It means there’s been a problem identified and the authorities are looking to validate whether that’s true or not. The audit can be overwhelming and dire. It is time-consuming and often takes the focus away from what the agency is there for: take care of the patients. Potential outcomes of the ZPIC healthcare audit include suspension of payment, denial of payment, loss of the Medicare number, and referral to the OIG for enforcement action. It’s important that preventive measures are taken in advance so that if you are faced with this audit, you can go through it smoothly.

Prevention of ZPIC Audit

A healthcare facility can prevent a ZPIC healthcare audit by having a comprehensive audit program in the place prepared with the help of a compliance specialist like Medlinks Cost Containment that understands the healthcare regulatory environment. You need to have a pre-claim review process that looks at every claim before it’s dropped for billing to make sure it is meeting the regulatory and eligibility requirements. Healthcare facilities should educate their staff on these requirements so that they are always one step ahead. They must listen to any employee or beneficiary concerns as part of their compliance program. Self-checks during an annual internal audit are critical just to make sure that you are in line with the regulations. When you are doing the preventive action of having a compliance program, educating your staff, making corrections when errors are found, then you are less likely to be a target for the ZPIC healthcare audit.

Why You Need A Comprehensive Internal Audit Program

A comprehensive internal audit program will allow healthcare facilities to stay ahead of the ever-changing regulatory environment. There are three main components of an internal audit program: monitoring regulations, auditing regulations, and educating staff. When you’re monitoring a regulatory environment, you should be looking at the OIG program — any of your local or national healthcare coverage determinations. You want to make sure that the audit program has an effective review methodology and clear audit steps. Make sure that the staff is aware of any sort of regulatory changes, findings, and recommendations from your audit, and recommendations that were laid out — so they can implement it into their day-to-day processes.

Main Areas of Revenue Cycle Healthcare Facilities Need to Focus On

An internal audit program addresses risk over all the components of the revenue cycle. The three main areas of the revenue cycle are patient access, medical documentation in charge capture, and patient financial services. You want an internal audit or compliance program to review your patient access management in order to get an understanding of your patient intake process, make sure that patient information on the upfront is properly captured, and all the necessary documentation signatures are captured up front. Examples of patient access audits are an advanced beneficiary notice review, a Medicare secondary questionnaire review, an EMTALA compliance review, and more. A medical documentation review includes a coding specialist reviewing the medical records of an organization to ensure that the documentation from the physician or the coders is accurate and meets the regulatory requirements. Patient financial services assessment ensures that all claims are adjudicated properly, all charges are captured, and reimbursement is properly captured.

How Healthcare Facilities Can Protect Revenue

If we talk about key strategies to deal with denials, having a very strong, dependable first-level review process is critical. It’s incredibly essential to have it incorporated into your utilization review. Also, it’s important to have highly trained staff members that are best educated in that criteria, and know-how to utilize those tools — to make sure you’re getting the status right the first time. Data analytics has really taken its course throughout health care where CMS and even payers have started to adopt that, and instead of reviewing the medical record, they have chosen to deny and ask questions later in terms of that complex review.

Medlinks Cost Containment Helps You Prevent/Prepare for Audits

 Ensuring sustainable growth has become a serious challenge for healthcare facilities. Audits don’t make the job any easier. Medlinks Cost Containment, with effective strategies and solutions, helps you not only prevent but prepare for medical audits including the ZPIC healthcare audit. Get in touch with us to avoid costly compliance errors and improve your bottom line. Have questions about our services? We are happy to answer!

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