Zone Program Integrity Contractors (ZPIC) investigate instances of suspected Medicare fraud, waste, and abuse. ZPICs perform a medical review and data analysis.
During a ZPIC audit, the contractor may request and review medical records, conduct patient interviews, conduct site visits, identify the need for prepayment or auto-denial claim edits, withhold payments, and refer cases of suspected Medicare fraud to law enforcement.
If a MAC investigates a provider for improper billing and the MAC is unable to dismiss the behavior as an error or misunderstanding, the issue is referred to the ZPIC. The ZPIC auditor will then perform one or more of the following:
If the ZPIC audit reveals a pattern of improper Medicare billing, the ZPIC auditors will discuss the issue with the Office of Inspector General (OIG). The ZPIC will get a recommendation whether or not to investigate further from the OIG.
If, after further investigation by the ZPIC, it is determined that potential fraud exists, the “case” is then referred to OIG. The ZPICs work closely with the FBI and they are able to essentially raid medical provider’s offices and copy documents under the power of the federal government.
Medicare ZPIC audits are very troubling and should never be handled without an experienced Medicare fraud defense attorney. Often these ZPIC audits result in Civil Monetary Penalties (CMP) and criminal charges. Therefore, please contact Chapman Law Group immediately if you receive notification of a ZPIC audit.
If the ZPIC determines that a medical provider is engaging in improper Medicare billing, but the practice does not warrant criminal action, the ZPIC can educate the provider on more appropriate billing practices.
The ZPIC may simply inform the provider of the improper practice, educate the provider on the correct procedure to be followed, and inform the provider that continuation of the improper practice may result in administrative sanctions.
If the ZPIC decides to only educate or warn the provider, a detailed report is created and may be submitted to the OIG for future reference.
If the ZPIC determines payment should be withheld for a claim and the provider disagrees, the medical provider can appeal the denial to the Medicare Administrative Contractor (MAC). Upon notice of the appeal, the MAC should request the file from the ZPIC. The ZPIC should furnish the file to the MAC within 7 days.
If a physician or medical provider believes that they have received a notice of an audit or claims review from a ZPIC, this notice should be taken very seriously and will likely lead to a negative outcome. The ZPIC can take several corrective actions against the provider if they determine fraudulent billing practices are occurring. The ZPIC can issue warnings, revoke a provider’s assignment privileges, suspend a provider’s payments, recover overpayments made to a provider, report the provider to the OIG and report the provider to state licensing boards.
You can count on the expertise of our Medicaid, Medicare, and third-party payor audit attorneys. For 35-plus years, we have been representing practices and providers nationwide on ZPIC, RAC, MAC, Safeguard (PSC), and Comprehensive Error Rate Testing (CERT) audits.
At Chapman Law Group, we work with health care providers and medical practices throughout the U.S., with four national offices:
Call us today and we’ll be happy to provide a consultation.
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