A Zone Program Integrity Contractor (ZPIC) performs an audit of medical professionals on behalf of the Centers for Medicare and Medicaid Services (CMS). The primary goals of these ZPICs is to identify cases of suspected Medicare and Medicaid fraud, take action to stop the fraudulent behavior, and recoup any misappropriated funds paid out to them. This is accomplished with the use of audits that look for inconsistencies and outright abuses of the system.
Who Gets Audited by the ZPICs?
One of the most troubling aspects of this program is that a company doesn’t know they are going to get audited. The process of picking a particular business to audit is one that is completely random. This is just one of the reasons it’s important to keep impeccable records, so there are no questions should your business be chosen to be the recipient of a ZPIC audit.
What ZPICs Are Looking for While Investigating
Although it would seem that investigating and looking for fraudulent activity might be simple enough, this isn’t all there is to a ZPIC audit. When a ZPIC audits your records, he or she is evaluating the information available to ensure that the submitted service record was provided to the person stated. The ZPIC must also make the determination of whether the service was necessary and medically reasonable. As the ZPIC searches through your medical records, he or she will be verifying that the diagnosis matches the patient’s gender, age and the procedure performed.
Potential Fraud Red Flags
As the ZPIC combs through your records, missing pages, erased notes, late entries, and pages that seem to be randomly inserted are noted. If these types of inconsistencies are found in the records, it could be an indication of waste, abuse, or fraud. Even if there is no evidence that fraud exists, a ZPIC could conduct a series of reviews that could include requesting additional documentation to support a claim. It could also perform telephone interviews with those patients who were beneficiaries of the claimed services, search for evidence of past complaints or questionable behaviors, perform data analysis of relevant figures, or investigate in many other ways.
If your business received notification that it is the subject of a ZPIC audit, you probably have many questions including whether or not your medical records will pass his or her scrutiny. An attorney experienced in ZPIC audits can help protect your rights and make sure your business has a qualified legal team throughout the process.
Experienced ZPIC Audit Attorneys Can Help
Even if you think you haven’t done anything wrong or you feel as though all your records are in order, you have a lot at stake if you face a ZPIC audit. An audit is a serious matter and even small errors can cost you thousands of dollars in penalties. Don’t risk your business and finances by attempting to navigate an audit alone. Contact the attorneys of Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.