Articles

Articles 2017-09-12T11:48:54+00:00

What Hospitals Need To Know About ZPIC Audits

“Although all CMS payment audits should be taken seriously, a ZPIC audit poses the potential threat of a federal fraud investigation.”

In recent years, the Centers for Medicare & Medicaid Services (CMS) has increased the number of program contractors that review provider claims and payments (see the sidebar on page 2). The alphabet soup of CMS contractors can be confusing because they all share responsibility for identifying potential overpayments and conducting pre- and post-payment audits. A recent federal decision further empowers these contractors. They now have the authority to determine payment error rates that, in turn, may justify extrapolation of alleged error rates to the universe of claims beyond the original sample (Gentiva Healthcare Corp. v. Sebelius, No. 1:11-cv-00438, D.C.Cir. July 23, 2013). ZPICs contract with CMS to perform a unique role and responsibility. Although audits by other CMS contractors may result in a provider’s obligation to refund previous payments, a ZPIC audit may expose a provider or supplier to potential liability for fraud. Indeed, ZPICs function as the fraud detection arm of the Medicare Administrative Contractors (MACs) and are tasked with identifying instances of potential fraud that may result in large overpayments and/or referral to other government agencies, such as the Office of Inspector General (OIG), for further investigation.

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Improper Payments and Recovery Audits: Legislation, Implementation, and Analysis
by Garrett Hatch
Specialist in American National Government
October 18, 2013

As Congress searches for ways to generate savings, reduce the deficit, and fund federal programs,
it has held hearings and passed legislation to prevent and recover improper payments. Improper
payments—which exceeded $115 billion in FY2011—are payments made in an incorrect amount,
payments that should not have been made at all, or payments made to an ineligible recipient or for
an ineligible purpose. The total amount of improper payments may be even higher than reported
because several agencies have yet to determine improper payment amounts for many programs,
including some with billions of dollars in annual expenditures.

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9 Recent Hospital Bankruptcies, Closures
Written by Ayla Ellison | August 27, 2015

Here are nine hospitals and health systems that filed for bankruptcy protection or closed since June 2015.

1. Nye Regional Medical Center in Tonopah, Nev., closed it doors Aug. 21 due to financial troubles. The hospital has been struggling financially for years, and those troubles forced the facility to file for chapter 11 bankruptcy in December 2013.

2. Saint Michael’s Medical Center in Newark, N.J., filed for chapter 11 bankruptcy protection Aug. 10. The hospital is on track to post a $24 million operating loss this year.

3. Southern Regional Medical Center in Riverdale, Ga., filed for chapter 11 bankruptcy protection July 30.

4. Cheverly, Md.-based Dimensions Healthcare System announced plans to close 106-bed Laurel (Md.) Regional Hospital and replace it with an ambulatory services center. The ambulatory care center, which will offer emergency services, outpatient surgery and diagnostic imaging, is expected to be open on the hospital site by 2018.

5. Doctors Hospital of Michigan in Pontiac filed for chapter 11 bankruptcy protection July 24.

6. Parkview Adventist Medical Center in Brunswick, Maine, filed for chapter 11 bankruptcy protection June 16. The hospital, which has been struggling financially for years, closed its inpatient care facilities and emergency department a few days after its filing. Those services were moved to Brunswick, Maine-based Mid Coast Health Services — a system Parkview has since merged with.

7. The Woodlands, Texas-based Victory Healthcare filed for chapter 11 bankruptcy protection June 12. The system manages six for-profit medical and surgical centers in Texas.

8. Boston-based Partners HealthCare announced it will close its Union Hospital in Lynn, Mass.

9. Escondido, Calif.-based Palomar Health’s board of directors voted June 24 to shut down its hospital in downtown Escondido.

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