ZPIC Audit Process

Healthcare professionals that are suspected for Medicare fraud, abuse and waste may find themselves the target of a ZPIC audit. ZPIC stands for Zone Program Integrity Contractors, and they perform medical reviews and data analyses to determine if wrongdoing exists. Medicare ZPIC audits are extremely troubling, and they are best handled with the help of an experienced Medicare fraud defense lawyer.

The attorneys at Norman Spencer Law Group are at your service. In our 10 years of working in healthcare law, we have helped numerous clients through the Medicare audit processing, including those launched by MAC, RAC and ZPIC.

Once a ZPIC audit is launched, contractors may investigate the allegations of wrongdoing using a variety of methods. This can include requesting and reviewing medical records, conducting site visits and conducting patient interviews. Contractors may also withhold payments, require edits for prepayment or auto-denial claims, or even refer suspected incidents of Medicare fraud to law enforcement authorities.

Audits by Medicare Administrative Contractors (MAC) may also be referred to ZPIC if the MAC is unable to dismiss the incident as a misunderstanding or error. When conducting an audit, the ZPIC investigators may perform one of more of the following actions:

• Review a sample batch of claims
• Interview patients
• Interview employees at the practice, the provider’s office or in their homes
• Explore previous violations by the healthcare provider
• Conduct data analysis

If the ZPIC audit uncovers a pattern of improper Medicare billing, the contractors bring the issue to the Office of Inspector General (OIG). The OIG has been the leading force fighting fraud, waste and abuse in Medicare and other government programs since its establishment in 1976. The OIG reviews the issue and makes a recommendation to ZPIC on whether or not the case merits further investigation by ZPIC auditors.

If ZPIC auditors further the investigation and find potential fraud exists, the case is officially handed over to the OIG. ZPICs work closely with the FBI, allowing them to essentially raid healthcare professionals’ offices and make copies of documents under the authority of the federal government. Due to the severe nature of ZPIC audits, it’s evident how and why the help of an experienced Medicare fraud defense lawyer is essential.

ZPIC audits can result in a number of penalties, including civil monetary penalties (CMP) and criminal charges. Criminal charges, in turn, can result in fines and jail time, depending on the outcome.

Not all improper Medicare billing incidents result in criminal action, although it’s vital to be prepared. It’s recommend that healthcare providers who find themselves the target of a ZPIC audit contact the legal team at Norman Spencer Law Group immediately.

If ZPIC find that a healthcare professional is engaging in erroneous Medicare billing, but the practice doesn’t warrant criminal action, ZPIC auditors have the option of educating the professional.

In such cases, ZPIC can outline the improper billing practice in which the healthcare professional had been engaged and educate the provider on the proper procedure to follow going forward. The healthcare provider will also be advised that continuation of improper billing practices may result in administrative sanctions.

When ZPIC chooses to only educate or warn the healthcare professional, contractors create a detailed report that may be sent to the OIG to keep on file for future reference.

In cases where ZPIC decides payment needs to be withheld for a claim but the healthcare provider disagrees, the provider can appeal the denial. In such cases, appeals need to be submitted directly to MAC. Once MAC receives notification of the appeal, its next move is to request the file from ZPIC. ZPIC has seven days to send MAC the file.

Licensed healthcare providers that believe they received a claims review or notice of audit from ZPIC need to take the notice very seriously. In many cases, ZPIC audits and claims reviews result in a negative outcome.

ZPIC auditors can take a number of corrective actions against a healthcare professional if they determine fraudulent billing practices exist. In minor cases, healthcare providers will be issued a warning. In more severe cases, ZPIC may revoke a practitioner’s assignment privileges, suspend a practitioner’s payments, or recover overpayments that have already been made to the healthcare professional. Additional options include reporting the practitioner to the OIG and state licensing boards.

Taking swift and efficient action upon receipt of a ZPIC notification is essential, and this is best done under the guidance of an experienced healthcare law attorney. The legal team at Norman Spencer Law Group has helped numerous licensed healthcare professionals through all stages of the ZPIC auditing process, from receipt of the initial notification all the way through the appeals. Contact our office to schedule a consultation today.