The Texas Medical Association can help physicians take the steps necessary to avoid trouble. For example, one of a practice’s best lines of defense lies in reg- ular coding and documentation audits, whether performed internally or by an outside consultant. (See “Audit Anxiety? TMA Can Help,” at right.) Dr. Clark says he’s learned a few les-
sons from the ZPIC audit experience. He has had two companies thoroughly re- view his charts.
“I’ve made changes so when my docu- mentation is examined, it’s cleaner,” he said.
He encourages his colleagues to work with a qualified and trusted adviser who can make sure they follow the exact bill- ing and coding guidelines for every form of insurance accepted. “You may still be audited because of the volume of work you do, but you can at least take steps to see to it your docu- mentation will hold up under scrutiny,” he said.
ZPICs different Mr. Chouteau says the following charac- teristics differentiate ZPICs from other audit programs:
• They are not bounty hunters because they are paid on a contractual basis and don’t get contingency fees.
• They review pre- and post-payment claims.
• There is no limit to their look-back period.
• Their primary goal is to identify sus- pected fraud and take immediate action with suspension of payments, denial of payments, or recoupment.
He also notes that ZPICs refer truly
egregious cases to OIG for civil or crimi- nal prosecution, which could result in recovery of three times the amount of actual financial losses suffered or im- prisonment. There are seven ZPIC zones. Texas is part of Zone 4, along with Colorado, New Mexico, and Oklahoma. The ZPIC for Texas is Health Integrity, LLC, www
.healthintegrity.org/html/contracts/zpic/ index.html, based in Maryland. When conducting pre- and post-pay-
Audit anxiety? TMA can help
TMA encourages physicians and their staff to be proactive in pre- venting an audit and can help medical practices avoid nightmares. TMA Practice Consulting offers evaluation and management (E&M) coding and documentation reviews that include a claims coding and medical record documentation analysis of 10 records per physician. An abbreviated checkup and a full review are available. TMA Practice Consulting also can conduct a coding and docu-
mentation quarterly review to determine whether a medical practice is following payers’ guidelines for appropriate billing year-round. And TMA Practice Consulting offers a training program for
practices that need help understanding documentation guidelines or identifying inappropriate or inaccurate coding and weaknesses in medical record documentation. The two-hour session covers a review of 1995 and 1997 E&M documentation guidelines, time-based coding, modifiers, and audit triggers, among other topics. Services are available for a fee based on a practice’s needs. To get an idea of your practice’s coding pattern, call TMA Prac-
tice Consulting at (800) 523-8776 or email
practice.consulting@
texmed.org.
TMA also published TMA Practice E-Tips Greatest Hits, Vol. 3:
Coding. The PDF, available free of charge on the TMA website, www
.texmed.org/template.aspx?id=1492, has helpful information and resources for ensuring correct coding. In addition, TMA’s webinar, Avoiding RAC Audits, examines the benefits of self-audits. Discover the top billing and coding risks, when and how to conduct a self-audit, what to do with your find- ings, and how to get buy-in for corrective action. Like all webinars in TMA’s Distance Learning Center, www.texmed
.org/
distance.aspx, Avoiding RAC Audits lasts one hour, and offers 1 hour of AMA PRA Category 1 CreditTM
.
If you have questions about a RAC audit, contact TMA Reim- bursement Specialist Erin Gregorcyk Smith at
Erin.Smith@texmed .org or (800) 880-1300, ext. 1407, or (512) 370-1407.
September 2011 TEXAS MEDICINE 23
ment claim audits, ZPICs may request documentation on all claims they believe are wrong. They may make an on-site visit on short notice, as well. Mr. Chouteau says if the ZPIC deter- mines a physician has been overpaid, it sends the physician a letter informing him or her of its decision. That is fol-
lowed by a letter from the MAC, de- manding repayment. The appeal process for ZPIC determi- nations involves five steps:
1. Submit a request for redetermination to the MAC along with supporting documentation.
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56