When a ZPIC investigates your organization for Medicare fraud, it will conduct multiple types of investigations to determine whether the alleged fraud occurred, and its magnitude. ZPIC reviews will also be used to determine whether Medicare payments to your organizations were appropriate, even if there is no evidence that you committed fraud.
Although it sounds intimidating and overwhelming, the investigation might be less painful than you imagine. To give you an idea of what to expect, here is a look at some of the investigative methods a ZPIC may use.
ZPIC Audit Investigative Methods
Often, the ZPIC will review a sample of the claims you have submitted recently to look for evidence of unjustified payments or fraud. Such a review may include requests for documentation or other evidence.
The ZPIC may also interview beneficiaries, usually by telephone. You needn’t worry about the ZPIC interviewers causing your patients any alarm. The purpose of the interview is to determine whether a questionable claim is a one-time error.
Additionally, the ZPIC auditors may look for comparable Medicare violations in the past, or instances in the past when you have been contacted by another Medicare contractor regarding such violations. These could include warning letters, educational letters, or contact reports.
Other investigative methods could include:
- Data analysis and analysis of procedures performed
- Random validation checks of the licenses of physicians in your organization
- Reviews of telephone calls or written questionnaires confirming the need for DME or home health services
Investigative methods can also include the comparison of practice and billing trends against local, national, and regional trends, as well as review of certificates of medical necessity. These investigative methods will help the ZPIC determine whether fraud has taken place.
There are other methods that could be part of the investigation. In order to ensure you are prepared as much as possible, it’s important to have a legal team on your side who have been through the process. Although the investigation itself can be scary, it can be less stressful for you and your staff if you have people who have experience with ZPIC audits on your side.
Qualified ZPIC Attorneys at Oberheiden & McMurrey, LLP
Fortunately, you don’t have to navigate the investigation or the ZPIC audit alone. In fact, it’s best for your business to consult a qualified ZPIC audit attorney as soon as possible. If you have been contacted about a ZPIC investigation, you should call us immediately for a consultation. Don’t risk making serious mistakes or accidentally failing to provide the information requested.
To learn more about a ZPIC audit and what you can expect throughout the investigation, the audit, and even the appeal process, you can speak with one of our attorneys at Oberheiden & McMurrey, LLP. You have a lot on the line and should make sure you have someone on your side to represent your best interests. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.