CMS Removes ZPIC Prepayment Review

Zone Program Integrity Contractor (ZPIC) evaluations have been occurring throughout the country, including Virginia.  A high number of evaluations have been focused on facilities in Florida. Over the past few months, the American Health Care Association (AHCA) has been working with the Florida Health Care Association (FHCA) to communicate to the Centers for Medicare and Medicaid Services (CMS) concerns with several aspects of the evaluation process, including the prepayment review audits conducted by Medicare Administrative Contractors (MACs), as instructed by ZPICs.  AHCA and FHCA recently had a joint conference call with CMS Administrator Marilyn Tavenner and reiterated concerns with the ZPIC encouraged MAC prepayment audits, as well as concerns with the general lack of transparency and communication between the ZPICs and providers.  

Prior to speaking with CMS Administrator Tavenner, AHCA had written correspondence and followed up that correspondence with a meeting with Dr. Peter Budetti, CMS Deputy Administrator and Director of the Integrity Program, and his staff to discuss our specific concerns.  As a result of that meeting, CMS requested verifying documentation, and 15 FHCA members submitted materials.

Last week, AHCA was notified that effective August 23rd, CMS will lift the prepayment reviews attached to ZPIC evaluations. This means that all SNF claims received on or after August 23rd are subject to post payment review.  A letter from Dr. Budetti, which confirms the change in writing, is available.  According to AHCA President Mark Parkinson, this action by CMS is a step in the right direction towards a clear set of standards with reasonable timelines and better communication with our providers.

However, a number of questions regarding this issue remain, including what this action means for those providers that have already had payments withheld.  An additional question has been directed to AHCA in connection with Additional Documentation Requests (ADR) and the practice of withholding payment now being followed by J11 Medicare Administrative Contractor, Palmetto GBA.  Given the CMS decision to suspend prepayment review in connection with more severe ZPIC evaluation activities, it logically follows that withholding payment in connection with ADRs should be suspended as well.  We will continue to monitor the discussions with CMS and other officials for answers and further clarification and will keep you posted.