Transcript ZPIC Zone 2 Technical Understanding

Overview of ZPICs
Curtis Watkins – Program Director
AdvanceMed Corporation
October 21, 2009
C S C. C O M
Advancing Healthcare Integrity
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ZPIC: Zone Program Integrity Contractor
• Replacing current Program Safeguard Contractors
– Combined oversight of Medicare Parts A, B, DME, Home Health
and Hospice
– Potentially will combine oversight of Medicare Parts C and D
• CMS will award 7 umbrella contracts with each containing 2
simultaneously awarded task orders
– Task Order 1 is Medicare Parts A, B, DME, Home Health, and
Hospice
– Task Order 2 is Medicare/Medicaid Data Matching Projects
– Future task orders will be awarded at CMS discretion for
activities related to fraud, waste, and abuse detection and
prevention
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ZPIC Zone Alignment
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2 - AdvanceMed
3
1
4 – Health Integrity, LLC
5 - AdvanceMed
2
7 – SafeGuard
Services LLC
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*Other territories of Zone 1 include American Samoa, Northern Marianas Islands and Guam
Puerto Rico
U.S. Virgin Islands
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ZPIC Zone 5
• Awarded September 30, 2009
• Transition period September 30 – December 15, 2009
• Fully operational December 16, 2009 – November 30, 2014
• 10 states, including:
– Alabama
– Arkansas
– Georgia
– Louisiana
– Mississippi
– North Carolina
– South Carolina
– Tennessee
– West Virginia
– Virginia
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ZPIC Zone 5
• Offices located in:
– Nashville, Tennessee
– Birmingham, Alabama
– Little Rock, Arkansas
– Baton Rouge, Louisiana
– Raleigh, North Carolina
– Baltimore, Maryland
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ZPIC Statement of Work Highlights
• Reactive and proactive identification of potential fraud, waste,
and abuse
– Data analysis
– Evaluation of complaints
– Referrals from law enforcement
– Fraud alerts
– Referrals from MACs and ACs
• Support for law enforcement during investigation and
prosecution of healthcare fraud cases
– Medical review
– Data analysis
– Overpayment determination
– Subject matter expert testimony
• Fraud, waste, and abuse training for MAC and AC staff
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Task Order 1
Medicare Parts A, B, DME, Home Health, and Hospice
• Centralizes all Medicare fraud, waste, and abuse work under a single
contractor
• Transitions workload from 3 PSCs to 1 ZPIC in Tennessee
• Focus is on cross-claims analysis and development of workload
across multiple benefit types
• AdvanceMed will house up to eight years of claims data for all benefit
types for all beneficiaries and providers within the zone
• Designates full-time Medical Director
• Initial priorities will include:
– Identity theft (beneficiary and provider)
– Infusion therapy
– DME
– Benefits related to psychiatric services (A, B, Home Health, and Hospice)
• CMS considering High Risk zones in Louisiana and North Carolina
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Task Order 2
Medicare/Medicaid Data Matching Project
• CMS plans to implement Medi-Medi projects in all 10 states in
the zone
• Medi-Medi combines all Medicare and Medicaid data for each
state into a single data repository for proactive analysis
• All Medicaid claim types, including children’s services and
dental are included
• All priorities are established by Steering Committee consisting
of members from CMS, state Medicaid Program, OIG, FBI, US
Attorney, DEA, IRS, and MFCU
• Tennessee Medi-Medi project tentatively scheduled for
implementation after September 1, 2010
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ZPIC Facts
• We are not reimbursed based on volume of referrals to law
enforcement or value of overpayments determined or
collected
• ZPICs are administrative contractors with authority to:
– Conduct prepay and/or postpay medical review
– Conduct announced and/or unannounced onsite audits
– Determine and refer actual or extrapolated overpayments for
recoupment
– Suspend provider payments, based on approval from CMS
– Refer providers and beneficiaries to law enforcement
– Conduct beneficiary interviews
– Refer providers for exclusion from Medicare program
• Providers are guaranteed appeal rights related to all
overpayment determinations
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AdvanceMed contact for ZPIC
Curtis Watkins
Deputy Zone Program Director/Benefit Integrity Manager
[email protected]
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