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Notes from American Health Lawyers Association (AHLA) Presentation on Post Payment Audits

On February 20, 2014, Brian Daucher and Claudia Reingruber (Reingruber & Assoicates) presented “Medicare Post Payment Audits (RACs, ZPICs, and Other Tools)” to the American Health Lawyers Association Annual Meeting for Long Term Care and the Law Conference in Las Vegas, Nevada.  The presentation covers the structure and operational characteristics of Zone Program Integrity Contractors, tools to prepare for such audits, and advice about useful appeal arguments related to such audits.  Here are some key takeaways.

The post payment auditing system is constantly evolving including:

  • Replacement of RACs with Regional Auditors, including one dedicated to Home Health & Hospice
  • Replacement of ZPICs and MIC with UPICs (Unified Program Integrity Contractors)
  • Ongoing utilization by CMS of automatic reopenings through Informational Unsolicited Response action.

The appeals system is breaking under the strain of additional appeals flowing in from MACs, RACs, ZPICs, and the IURs.  Providers face a 2+ year backlog at the ALJ level and increasing delays at lower levels as well.  As an initial step, CMS has finally suspended further RAC auditing pending RAC re-authorization.  CMS promotes additional post payment appeals, but has failed to fund the appeals system to ensure that providers are treated fairly.

For hospices:

  • Medical necessity audits are giving way to face to face and related care audits, which will be easier for the new Home Health and Hospice RAC to audit.
  • Drug reporting requirements will be followed by more scrutiny of formulary decisions.
Copyright © 2020, Sheppard Mullin Richter & Hampton LLP.National Law Review, Volume IV, Number 71


About this Author

Brian M. Daucher Sheppard Mullin Law Firm Orange County Business Litigator

Brian Daucher specializes in business litigation with emphasis on contract, health care, and intellectual property disputes. Mr. Daucher has represented clients in a wide range of industries including technology, consumer products, fiduciary and banking services, food and alcohol, health care, and energy.

Key Experience

  • Won $16 million arbitration award against Dentsply international for willful trademark infringement.
  • Defeated $66 million earn-out claim by seller brought against major sports clothing and equipment manufacturer.
  • Won $...