teau says the contractors have the power to place a practice under 100-percent prepayment review, which can’t be ap- pealed. At press time, he was represent- ing a Texas practice that was subject to 100-percent prepayment review. “It will take the group 45 to 60 days to
get the results of each claim submitted. If the claim is denied, the group has to go through an appeal process each time. Every claim the group gets back includes a letter requesting additional documen- tation. In one week, the practice re- ceived 700 of those letters,” he said. Mr. Chouteau emphasizes physicians should take ZPIC audits and investiga- tions seriously. He says most clients wait to contact him for help until the audit is complete and the physician receives the MAC letter demanding recoupment. He recommends physicians contact a lawyer with experience in audits upon hearing from a ZPIC or any other program. “It’s amazing to me how nonchalant many physicians are about providing a number of records to a ZPIC adminis- trator. Physicians don’t cull through the records first to ensure they’re complete,” he said.
He adds that in many cases physi-
cians need to go beyond their records to prove medical necessity to an audi- tor. For instance, a specialist may see a patient on referral from a primary care physician and bill Medicare for treat- ment. When an auditor requests that patient’s chart, the specialist should con- tact the primary care physician for the record to show medical necessity for the specialist’s treatment, Mr. Chouteau says. For Dr. Clark, the ZPIC audit has tak-
en an emotional and financial toll. He says he first went through a brief period of anger followed by grief upon learning of TrailBlazer’s determination. He also has spent $30,000 in legal fees through- out the process. “This has been a long and difficult
ordeal. I won’t give up seeing Medicare patients, and I’m hopeful the appeal pro- cess will bring about some relief when all is said and done.”
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September 2011 TEXAS MEDICINE 25
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