What Happens in the ZPIC Audit Appeals Process?

Each year, hundreds of providers find themselves audited by ZPICs. As these overseers scrutinize account books and procedures to find signs of fraud or Medicare abuse, there is little you can do to prevent an audit other than ensure you’re adhering to guidelines at all times.

If you do find yourself audited, or worse yet, accused of Medicare fraud, most lawyers agree that you should immediately appeal the decision and attempt to fight it. The ZPIC audit appeals process follows this five-step procedure for all appeals.

Redetermination

The first step in a ZPIC appeal is redetermination. This essentially means that a Medicare Administrative Contractor (MAC) will review your information and attempt to determine whether or not there was enough evidence of abuse or fraud on a claim to warrant an audit or action against you. The main goal of this step is to eliminate any potential cognitive bias or assumption that may exist. You have up to 120 days to file a redetermination appeal.

If a second auditor also agrees that there is evidence of Medicare abuse, the appeal may fail at this step. You can then file at the next level, a reconsideration appeal.

Reconsideration

If your redetermination appeal fails, you can request that a Qualified Independent Contractor (QIC) reviews your case through a reconsideration appeal. The QIC cannot have been involved in the redetermination appeal and must view the evidence with fresh eyes.

Within 60 days, the QIC will send a decision in writing. If this step also fails, you move on to an Administrative Law Judge (ALJ) hearing.

Administrative Law Judge (ALJ)

The ALJ hearing gives you the opportunity to explain your case to yet another individual who wasn’t involved in the original two appeal levels. This step allows you to explain the evidence in person. However, not every provider is entitled to an ALJ hearing; the total of the claim must be over $160 to qualify.

Like the QIC, the ALJ will make a decision independently and provide it in writing. If it fails, the next step is to take your appeal to the Medicare Appeals Council (MAC).

Medicare Appeals Council (MAC)

If you refute the ALJ’s decision, he or she will provide you with instructions for contacting the MAC. You can apply to the MAC for a full review, in writing, at the address provided to you by the ALJ. If you are unsatisfied with the MAC’s decision, or if they fail to provide a response within a timely manner, you may be able to bring your case to the Federal District Court (FDC).

Federal District Court

Most Medicare audit appeals never reach the Federal District Court; only cases with a claim amount for over $1,560 have the ability to access the FDC. If you qualify, and you assert that you do not agree with the MAC’s decision, the MAC will provide you with the information needed to schedule your day in court. It is highly recommended that you do not approach this highest level of appeal without a lawyer by your side. If you’ve reached the fifth level of appeal, consult a Medicare audit lawyer immediately.

In any event, the appeals process of an audit can be just as overwhelming as the audit itself. Contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.