In order for you to prevail in ZPIC audits, you should understand what a ZPIC is. The Zone Program Integrity Contractor or ZPIC was formed by CMS aiming to identify cases of fraudulent activities. The seven ZPICs across the country mimics the laws and regulations of the Medicare Administrative Contractor who are responsible to pay Medicare claims for services provided in the region.
CMS has provided ZPIC approval to certain functions and responsibilities which may include identifying program accountability, potential fraud, and implementing appropriate administrative actions like denying payments that should not be made by providers if proven guilty of fraud. However, you must also be aware of the activities that are not covered by the ZPIC and should be done by MAC. These may include claim processing, payment determinations, non-fraud related medical reviews and provider outreach and education.
How to Respond to a ZPIC Audit.
A ZPIC representative will usually try to reach just about anyone in your organization. Before your staff spills the beans, it is best that they are knowledgeable about the information that they can provide without risking all of your freedom and jobs. When one of your staff gets a call from ZPIC, quickly do something about it. It is best to seek legal representation before disclosing any important information.
A health care attorney is the best option to talk to. He would be able to educate you and your team about dealing with the ZPIC auditors. Any outcome of the investigation usually depends on how you dealt with the issue even at the beginning. It is best to prepare yourself and your employees.
Steps to Succeed in a ZPIC Audit.
- Understand and acknowledge the issue.
ZPIC aims to uncover any fraudulent activity. However, remember that they do not investigate fraud. They are contracted to identify fraud then refer the case to a law enforcement agency for civil or criminal prosecution.
- Understand the ZPIC’s role and responsibilities.
Healthcare fraud should be investigated intensively. When the information gathered from beneficiaries do not match with the claims for services or the medical records, this is suspicious and will be raised. You should also understand the Local Coverage Determinations established by the MAC’s. A provider who is not licensed will not be entitled to reimbursement for Medicare services.
Oberheiden and McMurrey, LLP.
This is a group of Medicare fraud prosecutors and law enforcement officers that have firsthand experience with numerous ZPIC audits. They are able to help clients with better understanding what the government lawyers are looking for when they ask to review your healthcare data and ZPIC information.
Attorney Lynette S. Byrd specializes in civil and criminal legal proceedings, Medicare and insurance audits, and also provides general advice and counseling about health care law. She was once an Assistant United States Attorney with years of trial experience to back her up and has a holistic understanding of the law.
If in any case that you are contacted by a ZPIC representative, no need to panic. If you need a ZPIC Audit Attorney, you can directly contact Oberheiden & McMurrey, LLP to view their opinions and ideas with regards to your concern. Proper steps to follow will be discussed in order to avoid leading the audit to a much bigger Medicare investigation and cause problems to you, your staff, and your company.