What Happens After a ZPIC Audit?

If you are facing a ZPIC audit or you have gone through one, you might be wondering what happens afterward. In many cases the results are almost guaranteed to result in negative repercussions for the health care provider. However, there is also a possibility that you come out ahead. Here are a few of the different outcomes you can expect to face, depending on your situation, after a ZPIC audit.

Pre-Payment Review

The most likely result of a ZPIC audit is ZPIC enforcing a pre-payment review system for an indeterminate amount of time. This means they will review and approve a certain percent of the provider’s Medicare claims. The error rate in payments that ZPIC finds in their investigation determines the percentage of current and future cases they will review. Pre-payment reviews of 100% result in ZPIC reviewing every Medicare claim and withholding the provider’s claims until the audit concludes.

Monetary Compensation

ZPIC can reclaim cases that resulted in overpayments. How ZPIC does this is at their discretion, based on the severity of their charges against the provider. They can go through each case or impose a fee based on extrapolation of previous overpayments.

In the Case of Fraud

If ZPIC suspects any fraud after the audit, they must report the health provider to law enforcement agencies. They only need to have the slightest evidence of fraud to report the health care provider regardless of the amount in question. Law agencies involved can include the Office of Inspector General. There is a 90-day time frame where the Office of Inspector General must either reject the case or escalate it to the Department of Justice.

Blacklist or Revocation of License

The worst-case scenario happens when ZPIC blacklists the health provider from Medicare. The provider must cooperate and oblige to ZPIC’s requests. If the provider is uncooperative during ZPIC’s investigations or attempts to circumvent this mandate then they may have their license revoked.

The outcome of a ZPIC audit depends on what they find in their investigation. The defendant can challenge these results to an extent since ZPIC has a large amount of discretion and freedom to enact whatever repercussions they think are suitable so long as they have sufficient evidence and reason. Depending on the case, there could also be criminal charges and jail time.

Experienced ZPIC Audit Attorneys at Oberheiden & McMurrey

As you can see, a ZPIC audit can have devastating effects on your business, from lost income to penalties and even the possibility of losing your business. At Oberheiden & McMurrey we understand that you have a lot on the line. Don’t risk the welfare of your business by putting your case in the wrong hands, or attempting to navigate a ZPIC audit alone.

Make sure you have the right legal team on your side to help you through it. If you are being audited or need help with an appeal, contact our attorneys at (888) 727-5159 or complete our online contact form today.