ZPICs focus on hospital staff credentials
Keep your licenses up to date
In addition to losing reimbursement when cases don’t meet medical necessity, hospitals face additional lost revenue if the credentials of all personnel who provide care for patients are not up to date and the staff are performing interventions for which they are not licensed.
The latest focus of Medicare’s Zone Program Integrity Contractors (ZPICs) is credentialing for hospital staff and physicians, says Brian Flood, CHC, CIG, AHFI, CFS, an attorney specializing in healthcare issues and partner with Brown McCarroll, LLP, in Austin, TX.
“The ZPICs are sending out letters requesting medical records as usual. Then they are showing up at the hospital and demanding to see the credentials of everyone who provided care for patients in those records. They are essentially cutting off the root of the tree,” he says. “If someone who provided care for a patient doesn’t have the proper license and credentials, then any service provided by that person can be disallowed. This can affect a vast amount of charges in a big hurry.” For instance, if a technician doesn’t have the proper credentials and license, the ZPIC could deny care for every patient he or she worked with for an entire year as a condition-of-payment violation or each isolated charge if it is a condition-of-participation violation. “Either way, it can be very expensive to respond to,” he says.
Focus on credentialing
The ZPICs’ focus on credentialing has caught hospitals by surprise, Flood says. “Hospitals are accustomed to having auditors review documentation and medical necessity. Now the ZPICs are going behind that and reviewing the people who are performing the services,” Flood says. The ZPICs are asking for far more than the credentials of the physicians. They also want credentials from the nursing staff and the technical staff such as the radiology technologists and phlebotomists, Flood adds.
“The biggest challenge institutions are facing is being prepared when the ZPICs ask for the credentials. In the hospitals I’ve worked with, it’s been a challenge to get everything together in the time the ZPIC auditors allow,” he says. ZPICs are requesting that all the records be provided to them in a single week, he adds. In many hospitals, records of staff licensure and credentials are not consolidated, Flood points out. In some hospitals, it’s not clear whether the hospital, the outpatient facility, or the provider groups are responsible for credentialing, he adds.
Zone Program Integrity Contractors are independent auditors hired by CMS to look for patterns of waste, fraud and abuse. The ZPICs are based on the Medicare Administrative Contractor (MAC) jurisdictions and started by auditing hospitals but eventually will audit all providers of services to Medicare. CMS pays ZPICs a contracted rate plus a contract award at the end of the year that is undefined in the guidelines, Flood says.
Unlike the MACs and RACs, which concentrate on fee-for-service Medicare claims, the Zone Program Integrity Contractors (ZPICs) will review all providers of Medicare and Medicaid services, including managed Medicare and Medicaid, Flood says.
The ZPIC initiative got off to a slower start than the Recovery Audit Contractors (RACs). Now all of the contractors are on board and are fully staffed, and hospitals are going to see much more of the ZPICs in 2013, Flood says.
“The ZPICs have the most authority out of all contractors in the alphabet soup of auditors. They have a mandate to review claims for Medicare fee-for-service, Medicare managed care, and Medicaid and report any patterns of fraud or abuse to the Office of the Inspector General. They are the auditors that hospitals need to pay a lot of attention to if they come knocking on the door and asking questions,” he says.
Hospitals should determine where all of the records of staff credentials and licensure are located, that they are current and that the full records are available.
He recommends that case management directors sit down with their staff and make sure everyone has the proper credentials and that every license is up to date, going back three years. Make sure that anyone who works with patients has the right licensure to perform the tasks he or she is assigned, he adds.
In addition to losing reimbursement when cases dont meet medical necessity, hospitals face additional lost revenue if the credentials of all personnel who provide care for patients are not up to date and the staff are performing interventions for which they are not licensed.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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