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I have registered a complaint with the SBA in regards to our status in a ZPIC audit.  I know many practices are dealing with this right now and hope that maybe this will assist us all if we register complaints about the system.  Our complaint was submitted as stated below. We are a small privately owned Orthotics and Prosthetics practice who have become caught up in the ZPIC (Pre-payment) Audits by CMS and its contracted auditors.  We have several concerns that seem to make “working our way out” seem virtually impossible.    1)      Our first and very valid concern is the documentation. A)     The LCD’s are very heavily worded and amended so frequently that it is difficult to know what is expected of you as far as documentation.  It almost always is open for interpretation.  What we believe is the correct way or what a particular seminar may have taught us, may very well be simply that individual’s interpretation and in reality may not meet the criteria of CMS or its many contracted auditors.  B)     The next portion of this concern reaches out to the Physician’s we are dependent upon for documentation that prevents payment to us for our services.   The physician can sign off and state that a patient is Diabetic, and qualifies for diabetic shoes because he has callus formation, on the CMS Certifying Statement form required for payment on diabetic shoes.  We then have to have progress notes to support the same information provided by the doctor signing off, so we request these records, but the doctor has not made written note of the callus formation in the record so we do not have the proper documentation.  This is impossible, unless we are there with each physician for each patient, we cannot monitor their record keeping, and who gives us as O&P providers this authority.    CMS is refusing to pay us for another’s actions.  Sending the letter that CMS provides to the Physician’s isn’t helpful as the letter like most requirements is open to varied interpretations. In addition, we are reliant on the Physician’s for referrals and they on us for our knowledge in Orthotics and Prosthetics yet CMS is pitting us against each other in the battle of documentation and the expectations that the Physician’s should not only do their jobs but also do ours, and tying our hands to assist in our areas of expertise. 2)      We have been in audit for almost one year!!! We are in survival mode at this point.  We had errors and made improvements but none of these things were direct fraud.  We have paid for the items provided to the patients and provided the services and yet we have not received payment.  As a contractor we are expected to continue to provide services to Medicare patients and continue to bill claims, but every claim goes into ZPIC, however if we don’t then that shows varied billing patterns that triggers yet another CMS red flag.   The paperwork always has a flaw of some sort ( it is impossible to comply when what you are complying with changes so frequently), and we end up going through every stage of appeal, which we are paying a contracting company to handle, and financially it is not logical to contest most claims under $500 dollars.  That is a lot of claims that will never see payment although the Physician prescribed them and we provided them, and the patient accepted them.   These claims are not even the most alarming, as the prosthetic claims that are tied up in this audit could support our small practice for the last year.   We are playing a game we can’t win with rules that change so frequently there is no way to play fair. 3)      The auditing groups are paid on monies that they recoup, yet they are the ones to review our submitted support documentation for compliance.  Why would they see any paperwork as compliant and loose the funds they are dependent on for financial gain?  The logical answer is that they wouldn’t.  This seems like a conflict of interest. 4)      We are not allowed to contact the auditing group.  We are only in contact by fax with a company that will not respond to us with anything more than a request for records and repeated denials of substantial paperwork forcing us to secure an outside source to handle the audit because they have professional contacts with the auditing groups.  This is a very costly solution to attempt to meet the requirements of CMS, notably when there is no payment for the products or services already paid for by our practice and provided to the patient per the physician order.  Are these auditing groups supervised?  Do they have rules and criteria?  We are simply told our claims have to improve to be taken off of the prepayment audit.  Improvement has happened, but we remain on audit with only very vague reasons for nonpayment. In closing, this is enough to put any standard private practice out of business.  The expenses we are being forced to incur are extreme, and all of this comes without a promise of any future payments.  We have no example of a perfect claim to file, and ever-changing rules, with 100% of our Medicare claims being sent to ZPIC.  The prevention of fraud to the system is understandable and justified but the system should not be fraudulently withholding payments from the suppliers either.  Brandy Carpenter Greeneville O&P