CMS Responds to Complaint on ZPIC
February 26, 2014 02:02 PM
In early November, 2013, the Zone Program Integrity Contractor (ZPIC), Health Integrity, issued an “educational letter” to a series of home health agencies that it had screened as potentially aberrant. For more, please see NAHC Report, November 7, 2013. That letter set out policy statements that were at odds with long-established Medicare law and policy. NAHC contacted the Centers for Medicare and Medicaid Services (CMS) demanding immediate action to correct the seriously deficient ZPIC.
After more than two months of repeated inquiries on the status of the matter, CMS issued a response:
“CMS recognizes that the letter, while providing educational guidance to the home health provider community, contained some broad generalities and technical inaccuracies, particularly with regard to the statements identified in your correspondence. As a result, CMS has directed Health Integrity to issue clarifying guidance to each recipient of the original educational letter.”
“We are pleased to see that CMS has taken affirmative steps to correct the serious misstatements of Medicare coverage standards expressed by its ZPIC,” stated William A. Dombi, NAHC’s Vice President for Law. “However, we remain very concerned that CMS did not order the ZPIC to reopen its past claim denials that were likely based on invalid policy standards.”
Dombi further indicated that NAHC has requested that CMS share a draft of the clarifying letter before it is issued. To date, CMS has not responded to that request. Affected providers should be on the lookout for the follow-up letter from Health Integrity. NAHC requests recipients to forward a copy to email@example.com when the letter is received.
NAHC views Medicare’s program integrity efforts as a two-way street. It is crucial that there be zero tolerance of fraud, waste and abuse regardless as to whether it is sourced from a home health agency or a Medicare contractor. Given the apparent unwillingness of CMS to fully correct any decisions issued by the ZPIC using its invalid coverage policy, home health agencies are strongly encouraged to utilize the administrative appeals process for protection. Further, affected agencies should consider forwarding information about erroneous claim denials to NAHC to pursue additional systemic corrective action from CMS.