How One Home Health Agency Restored Compliance After Failing Two ZPIC Audits

When a Home Care Agency (HHA) is compliant, the agency is submitting claims in accordance with the current Centers for Medicare and Medicaid (CMS) regulations.

The Medicare Integrity Program (MIP) was established to aid in CMS’s mission to detect and manage fraud. After the Medicare Modernization Act (MMA) took effect in 2003, CMS was required to use Medicare Administrative Contractors (MACs). As a result, “seven integrity zones were created based on the newly-established MAC jurisdictions, and new entities entitled, Zone Program Integrity Contractors (ZPICs) were created to perform program integrity functions in these zones for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, Supplies, Home Health and Hospice and Medicare and Medicaid.” As defined by CMS, “the primary goal of ZPICs is to investigate instances of suspected fraud, waste, and abuse. ZPICs develop investigations early, and in a timely manner, take immediate action to ensure that Medicare is not inappropriately paid. They also identify any improper payments that are to be recouped by the MAC.” If a ZPIC finds an agency warrants exclusion from participating in Medicare/Medicaid, they are required to make a recommendation to the Office of Inspection General (OIG).

In other words, if a ZPIC shows up at your door, your agency needs to be ready.

A large health system in Florida was a prime example of how an agency can struggle to achieve compliance. They were unable to successfully fill several key leadership roles within their home care agency after a loss of leadership. Eleven critical positions were vacant within the clinical, quality assurance, and finance departments. As a result, leadership, strategy, quality performance, and compliance profoundly suffered. The agency ultimately failed a ZPIC audit leading to a continual focused review by Medicare, which required an immediate billing shutdown and additional documentation requests (ADRs) on all episodes.

Following the failure of the ZPIC audit, two separate mock surveys conducted onsite indicated no improvement in any of the critical areas. The home care agency needed significant realignment before the surveyors came back onsite, or the agency was in severe jeopardy of shutting down.

To restore compliance and order within the agency, the health system hired consultants to provide interim management, compliance, and turnaround services to restore the organization. The consulting team filled in at interim status to not only temporarily fill the critical positions (such as CEO) to improve leadership relations, but also to achieve stability and compliance across the agency. To do this, the consultants established individual and departmental performance standards, clinical documentation best practices, reduced the backlog of OASIS submissions, conducted chart audits, developed QAPI structure and data measurements, and educated the team to ensure survey readiness.