Jackson Davis HealthCare
Medicare Audit Defense,
  Medicare Appeals & ZPIC Shadow Audits
Contact us at 
(303) 586-5003

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The Healthcare Provider's #1 Medicare Audit Defense & Medicare Appeals Team
ZPIC Audit Defense - ZPIC Appeals - Medicare Shadow Audits

Zone Program Integrity Contractors (Medicare ZPIC Auditors) Turn Up The Heat On Physicians, Hospices, Skilled Nursing Facilities, Home Health Agencies, Physical Therapists & DME Suppliers

While the Medicare Recovery Audit Contractor program (RAC Audits) continues to focus the majority of efforts toward hospital adoption of Medicare coverage policies, CMS has launched another major initiative to directly challenge all other providers.  Although the program - Medicare Zone Program Integrity Contractors (ZPIC audits) - was not officially rolled out with an emphasis on physicians, home health agencie, hospices, skilled nursing facilities, DME suppliers and physical therapy billing, that is exactly where it has been focusing efforts.

Across the southeast, south central, midwest, northeast and west coast regions of the U.S. - ZPIC auditors are in full force.  SafeGuard Services, AdvanceMed, Health Integrity and Integriguard are all pursuing providers with surprise on-site visits, targeted data analysis, random audits, 100% pre-payment holds, extrapolations and follow-up to whistleblower actions.

So, who are ZPIC auditors anyway?  Zone Program Integrity Contractors are organizations hired indirectly (or in connection with other CMS affiliated contractors) by CMS to perform a wide range of medical review, data analysis and Medicare audits.  While ZPIC audits are similar in many ways to other Medicare audits currently being performed nationwide they do differ in one very important aspect – potential
Medicare fraud
implications.  Of all the current CMS audit initiatives – RAC audits, MIC audits, etc. – it is vital that providers facing ZPIC audits immediately and effectively address targeted audit issues.

How Can Jackson Davis Help?

As your unwavering advocate, Jackson Davis HealthCare (JDH) leads the nation in assisting healthcare providers facing Medicare compliance challenges.  For over 25 years,
Jackson Davis HealthCare professionals have dedicated every day to understanding, documenting, synthesizing and applying Medicare Coverage Criteria for cases being considered for Medicare audits and Medicare appeals - ZPIC appeals, RAC appeals, DOJ appeals, MAC appeals, MIC appeals or individual Medicare beneficiary appeals.

Medicare Appeals (ZPIC appeals) / Medicare Shadow Audits - Over the past 25 years, Jackson Davis professionals have worked with providers nationwide to appeal 1,000s of Medicare overpayment issues and win close to 90% of all cases.  JDH partners with providers to analyze, develop & build winning Medicare appeals cases. Our board-certified physicians, legal nurse auditors and industry-leading compliance staff are unmatched in Medicare audit defense and the submission of winning Medicare appeals.  Simply put, NO ONE will give you a better chance to succeed at your Medicare appeals.

Medicare "Additional Documentation Request" Response (ZPIC auditor ADR response) - A provider's initial ADR response is a critical stage of the Medicare audit process.  Jackson Davis professionals are experts at developing a cohesive and winning approach to responding to ZPIC auditor requests for documentation.  NO ONE will give you a better chance to address and eliminate additional Medicare audit threats.

2013 Medicare Self-Audit Templates
- Are you looking to build a rock-solid internal audit & compliance program using Medicare coverage criteria as a foundation?  Have you been conditionally denied payment from a Medicare contractor and want to build winning appeals?  The 2013 Medicare self-audit templates are perfect for use by internal auditors and compliance professionals when reviewing potential Medicare focus areas and building winning Medicare appeals.  These detailed, self-audit templates are now available for purchase by healthcare providers nationwide.

Mock Medicare Program Integrity Audits (Mock Medicare Audits) - Jackson Davis HealthCare assists providers in completing proactive, medical records audits versus Medicare coverage criteria - Medicare Program Integrity audits (or "Mock" PI Audits). Each Medicare PI audit is based on documented, CMS payment criteria and Medicare coverage criteria for selected focus areas and may include a sampling of 10 - 500 patient encounters.  Each encounter is pre-screened and carefully selected based upon Medicare current or anticipated audit focus areas.

Internal Audit & Medicare Physician Advisor Program Development - Are you looking for a helping hand in developing or revamping your internal audit or Medicare physician advisor programs?  Are you looking for a reliable resource to work as a true partner in the process of adopting a more structured foundation built on Medicare coverage criteria?  Are you uncomfortable about facing prepay audits or want peer review of your external physician advisor group?  Jackson Davis is the solution.  Our board-certified physicians really do understand Medicare coverage criteria and they work closely with our legal nurses and regulatory team to bring compliant solutions to providers everyday.

CMS Compliance Advisory Services - Providers nationwide retain JDH for monthly audits, compliance advice or on a project-by-project basis.  Our staff is highly experienced and our knowledge and application of Medicare rules and regulations is unmatched in the industry.  We are true Medicare compliance geeks.  From our physicians to our nurses to our compliance research team, we are in your corner and available 24/7 for your CMS compliance needs.  Call us today for help with any medicare appeal issue - hospital appeals, snf appeals, home health appeals, physician appeals, hospice appeals and DME supplier appeals.

Medicare Audits & Medicare Appeals - $195 Webcasts - FY 2014 Winter / Spring Events

Join our industry-leading Medicare audit defense team and Medicare coverage criteria professionals for the nation's best Medicare audits and Medicare appeals webcasts! Call or e-mail us today for registration at support@jdhcare.com or (303) 586-5003.

January 21, 2014 - 2:00p - 3:30p EST
Inpatient Rehabilitation Facility - 2014 Medicare Coverage Criteria

This presentation will address Medicare Coverage Criteria for Inpatient Rehabilitation Facility admissions.  We will discuss the IRF "medical necessity" criteria and the full range of CMS documentation requirements for inpatient rehab providers.  This will be a detailed discussion of Medicare Benefit Policy Manual, Chapter 1, Section 110 and how MACs are applying coverage criteria to their audits.

Please send your registration request and contact information to us via e-mail at
support@jdhcare.com.  Registrations must be received no later than January 20 and you will receive an e-mail confirmation with sign-on information and password.  The cost is $195 per healthcare provider.

February 4, 2014 - 2:00p - 3:30p EST
Home Health Agencies - Homebound Status, Certification, Skilled Nursing Care & Physical Therapy

This presentation will address Home Health Agencies and ramped up CMS efforts to attack perceived overpayments to providers. Nationwide, ZPICs, RACs and MACs are out in full force to conditionally deny cases based upon homebound status, lack of certification, unnecessary skilled nursing care and medically inappropriate physical therapy services.  This is an OUTSTANDING presentation for home health providers and will focus on Medicare coverage criteria, responding to Medicare additional documentation requests and the filing of home health appeals.

Please send your registration request and contact information to us via e-mail at
support@jdhcare.com.  Registrations must be received no later than February 3 and you will receive an e-mail confirmation with sign-on information and password.  The cost is $195 per healthcare provider.

February 18, 2014 - 2:00p - 3:00p EST *** SPECIAL EVENT ***
ALJ Hearings - Update, Scheduling, Recoupment & Next Steps

The fallout continues....  It was inevitable...  ALJs are overloaded and the Office of Medicare Hearings & Appeals has suspended the assignment of ALJ hearing dates for the next 2 years!  65 ALJs and over 357,000 pending appeals - what did CMS think would happen?  CMS has 1,000s of contracted auditors pounding providers across-the-nation.  CMS has contracted with for-profit audit companies with every possible incentive to deny payment.  CMS has recoupment rules that clearly and unequivocally deny due process to providers.  We've got a national budget that can't possibly pay all the bills.  In short, we've got a train-wreck.  This detailed presentation will address the ALJ hearing suspension, recoupment concerns and strategies for moving forward.

This is a SPECIAL EVENT presentation and the cost will be $125 per provider (versus $195).  Please send your registration request and contact information to us via e-mail at
support@jdhcare.com.  Registrations and payment must be received no later than February 14 and you will receive an e-mail confirmation with sign-on information and password.  The cost is $125 per healthcare provider.

February 25, 2014 - 2:00p - 3:30p EST
The Medicare Appeals Process for Healthcare Providers - How to Win!

This presentation will address issues associated with Medicare audit defense strategies, Medicare appeals and Medicare shadow audits - RAC appeals, ZPIC appeals, DOJ appeals, OIG appeals, MAC appeals, Medicare overpayment determinations and the Medicare appeals process.  Through 2013, Jackson Davis has assisted providers in winning almost 90% of all Medicare appeals... and we will be in your corner!

As CMS continues to ramp up auditing efforts, providers nationwide are spending tens of millions of dollars on legal fees, repaying hundreds of millions of dollars to CMS for conditional denials and being exposed to potential Medicare fraud allegations.  This discussion will provide an in-depth look at the Medicare appeals process and explore a wide range of opportunities for providers to proactively build winning Medicare appeals (RAC appeals, ZPIC appeals, etc.).  The old days of soft regulations and provider education are over - it is absolutely vital that providers understand how the game has changed.

Please send your registration request and contact information to us via e-mail at
support@jdhcare.com.  Registrations must be received no later than February 17 and you will receive an e-mail confirmation with sign-on information and password. 
The cost is $195 per healthcare provider.

March 4, 2014 - 2:00p - 3:30p EST
Medicare Auditor Targeting of Skilled Nursing Facilities (Part A & Part B) - SNF "Medical Necessity", MDS Documentation & Therapy Services

Under fire from Medicare audits, SNFs can be highly susceptible to losses from missing documentation, "medical necessity" requirements, therapy services and challenges relating to appropriately billed MDS components for Medicare Part A and Part B coverage.  This presentation will address a wide range of topics including responding to Additional Documentation Requests from CMS and CMS contractors, applicability of acute stay documentation, developing SNF appeals, performing self-audits and the major target areas where providers struggle to win ZPIC audit cases.

Please send your registration request and contact information to us via e-mail at
support@jdhcare.com.  Registrations must be received no later than march 3 and you will receive an e-mail confirmation with sign-on information and password. The cost is $195 per healthcare provider.

March 18, 2014 - 2:00p - 3:30p EST
Hospice Care - Terminal Illness Certification... How long is too long?

This presentation will address one of the most frustrating and "grossly inappropriate" audit focus areas on the current CMS workplan... provider payments for the certification of terminally ill patients that live longer than 6 months.  Medicare contractors - and ZPIC auditors in particular - have attacked providers who care for terminally ill patients that actually live longer than their diagnosis-driven, average life expectancy of 6 months.  Not only are these Medicare auditors arbitrarily denying cases where patients live longer than average, they are extrapolating the outcomes into the millions of dollars for select hospice providers.

Please send your registration request and contact information to us via e-mail at
support@jdhcare.com.  Registrations must be received no later than March 17 and you will receive an e-mail confirmation with sign-on information and password.  The cost is $195 per healthcare provider.


ZPIC Audits - CMS Medical Review Process

Prior to the 1996 enactment of the Health Insurance Portability and Accountability Act (HIPAA), Medicare program safeguard activities were funded from the contracted fiscal intermediary’s general program management budget. However, HIPAA revised the Social Security Act and established the Medicare Integrity Program - accelerating today’s focus on Medicare audits, Medicare fraud, abuse and enforcement of CMS evidence-based coverage policies.

The Medicare Integrity Program’s (MIP) primary purpose is to deter fraud and abuse in the Medicare program by giving CMS authority to enter into contracts with outside entities and insure the “integrity” of the Medicare program.
In 1999, the Centers for Medicare & Medicaid Services (CMS) developed the PSC program to support the MIP, stop Medicare fraud and facilitate provider adherence to codified CMS Payment Criteria, Conditions of Participation and applicable judicial rulings.

ZPIC auditors (formerly known as Program Safeguard Contractors) have a contracted Statement of Work (SOW) that encompasses all of the fundamental activities required for CMS program safeguard activities. Basically, a ZPIC auditor is generally responsible for one or more of the following Medicare audit focus areas - (1) pre or post pay medical review of claims, (2) data analysis, (3) benefit integrity and/or fraud detection, (4) cost report audits and (5) provider education.

At the highest level, CMS considers an individual ZPIC as being responsible for detecting, deterring and even preventing Medicare fraud and abuse. In this capacity, the ZPIC auditor is directly responsible for operating areas such as investigation, case development, administrative solutions and referral to law enforcement.

With the establishment of ZPIC audits, fiscal intermediaries and Medicare administrative contractors typically have some or all of their program safeguard duties removed from the scope of their responsibility. Step-by-step, CMS appears to be developing a more concentrated functional contracting focus for specific areas such are benefit integrity and claims processing activities.

The CMS Medical Review (MR) program is designed to promote a structured approach in the interpretation and implementation of Medicare policy. The ultimate goal of the MR program is to identify and reduce Medicare program vulnerabilities (areas of potential Medicare fraud or abuse) relating to coverage and by taking the necessary action to prevent or address these areas.

The CMS’ national objectives and goals as they relate to medical review are as follows: 1) Increase the effectiveness of medical review payment safeguard activities; 2) Exercise accurate and defensible decision making on medical review of claims; and 3) Collaborate with other internal components and external entities to ensure correct claims payment, and to address situations of Medicare fraud, waste, and abuse.

In order to identify and challenge perceived Medicare fraud & abuse issues, ZPIC audits are based upon a combination of claims data from multiple sources (fiscal intermediary, regional home health intermediary, carrier, and durable medical equipment regional carrier data). By combining data that originates from a full range of CMS contractors, the Medicare ZPIC contractor creates a complete profile of the beneficiary’s claim history regardless of where the claim was processed.

Although Quality Improvement Organizations (QIOs) continue to perform reviews related to quality of care and expedited determinations, they no longer perform the majority of utilization reviews for acute PPS hospitals or LTCH claims. The review of acute PPS hospitals and LTCH claims is now the responsibility of other CMS program contractors including: Carriers, Fiscal Intermediaries (FIs), Program Safeguard Contractors (PSCs), Zone Program Integrity Contractors (ZPICs) and Medicare Administrative Contractors (MACs).

ZPIC Audit Outcomes, CMS Extrapolation & ZPIC Appeals

ZPIC auditors refer all identified overpayments to the Medicare affiliated contractor (typically a MAC), who subsequently sends the provider a demand letter for recoupment of the perceived overpayment. In any case involving an overpayment, even where there is a strong likelihood of Medicare fraud, the MAC will typically request recovery of the overpayment.

Under most circumstances, ZPIC audit contractors may use statistical sampling to calculate and project (i.e., extrapolate) the amount of overpayment(s) made on claims. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), mandates that before using extrapolation to determine overpayments, there must be a determination of sustained or high level of payment error, or documentation that educational intervention has failed to correct the payment error.

A sustained or high level of payment error may be determined to exist through a variety of means is not subject to administrative or judicial review. Examples include: error rate determinations by ZPIC audits / MAC audits, probe samples, data analysis, provider/supplier history, information from law enforcement investigations, allegations of wrongdoing by current or former employees of a provider and audits or evaluations conducted by the OIG.

If the provider elects to appeal a claim reviewed by a ZPIC, then the ZPIC forwards its records on the case to the CMS affiliated contractor (typically a MAC) so that it can handle the Medicare appeal. ZPICs are required to have a medical specialist involved in denials that are not based on the application of clearly articulated policy with clearly articulated rationale.