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ZPIC Audit Process

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:

    • Review of a sample of claims
    • Interview a number of patients
    • Interview employees at the provider’s office or at home
    • Look for previous violations by the provider
    • Perform data analysis

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.

ZPIC Appeals

If the ZPIC determines payment should be withheld for a claim and the provider disagrees, the medical provider can appeal the denial to the 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.

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