Although you might have heard of a ZPIC audit, you might not be entirely sure of what a Zone Protection Integrity Contractor (ZPIC) is or does. It’s no secret that government-provided health coverage is sometimes targeted by fraudsters. Zone Protection Integrity Contractors are one of several entities, created by the Centers for Medicare & Medicaid Services (CMS), charged with finding and putting an end to these cases of fraud.
Jurisdiction of a ZPIC in the United States
ZPICs are a specific category of entities that investigate potential fraud cases relating to Medicare Parts A and B, as well as prosthetics, orthotics, supplies, and home hospice care.
ZPICs in different parts of the country may be referred to by different names, based on which of the seven zones they represent. These are Safeguard Services (SGS, Zones 1 and 7), AdvanceMed (Zones 2 and 5), Cahaba (Zone 3), Health Integrity (Zone 4), and Under Protest (Zone 6). Each zone simply refers to a group of states or territories where these specific ZPIC entities operate.
Functions of a ZPIC
As you might guess, a ZPIC’s duties include more than just requesting documentation. ZPICs primarily investigate cases where fraud, waste, or abuse are suspected. They also provide support to victims of identity theft relating to Medicare services, which includes helping health care providers recoup expenses lost due to fraudulent claims.
What to Expect During a ZPIC Audit
ZPIC audits are often complex, but are performed simply to investigate the organization. During investigations, ZPICs are likely to request copies of all medical records and documentation, visit the provider site, and conduct interviews. For medical organizations and facilities, payments could be withheld if deemed appropriate by the investigator. This can become costly.
ZPICs do not handle complaints, audit cost reports, or process claims. All medical and documentation review is specifically for the purpose of verifying benefit integrity. While they relate findings of accidental overpayments to Medicare Administrative Contractors (MACs) for reimbursement, they do not provide education and outreach services in this purview.
If you find yourself under investigation of ZPICs, even if you have done nothing wrong, you should contact an attorney with experience in Medicare fraud defense as soon as possible. Cases can be referred to law enforcement, resulting in civil monetary penalties or criminal charges. A ZPIC audit can have a negative effect on your business and your life.
ZPIC Audit Attorneys at Oberheiden & McMurrey
Even if you don’t think you have done anything wrong, it’s in your best interests to let an experienced ZPIC audit attorney navigate the process on your behalf. ZPIC audits can be more complicated than you think and require an experienced legal team to make sure you get the best possible outcome. Don’t make a costly mistake by putting your business in the wrong person’s hands. If you are being audited or need help with an appeal, contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.