Medicare fraud and abuse are growing problems in the United States, both on the part of individual citizens and those who serve as their health care providers. This has led to an explosion of audits as the government attempts to save money by rooting out Medicare fraud and abuse. No provider ever wants to find out they’re being audited by a ZPIC, but the reality is that hundreds of providers are audited all across the United States each year. Here are the different types of formats most audits fall into and how to recognize which applies to you.
Automated audits are almost always a result of randomly-selected yearly audit quotas rather than specific evidence of fraud or abuse. Often, this type of audit doesn’t even request specific information; rather, they review what information they’ve received from you already.
While the likelihood of an accusation from an automated audit is low, it isn’t unheard of. If you find yourself randomly audited, you should still anticipate and prepare for the possibility of an appeal with an experienced ZPIC audit lawyer.
Semi-Automated ZPIC audits may be done on a random, anonymous basis, or they may be spurred on by weak evidence of an issue with payment claims. Either way, semi-automated audits are computer-generated and also come with a request for records and payment claims documentation. You may be asked to provide your total yearly documentation for Medicare claims or just a few records specific to a single claim. It is in your best interest to gather these documents, have them reviewed by a lawyer, and then submit them in a timely manner.
When a ZPIC auditor or Medicare Administrative Contractor (MAC) detects a specific problem, such as a lack of medical necessity of diagnostic testing, it may spur on a complex audit. This is the most robust form of audit and is typically (but not always) the most serious. In a complex audit, the MAC is likely to request extensive evidence of the claim’s necessity, eligibility, and protocol followed.
A complex audit requesting extensive information is likely to represent a suspicion of fraud or abuse on the part of Medicare, and should be taken even more seriously than automated and semi-automated audits. In most cases, a complex audit is a sign that the ZPIC or MAC has already detected a pattern of fraud or abuse somewhere in your payment claims. In most cases, it’s best that you do not attempt to respond to this or any audit without first contacting a ZPIC audit lawyer for assistance.
ZPIC Audit Attorneys Can Help with All Formats
No matter which type of audit you face, our attorneys are ready to help you through the process. We have the experience you need on your side to ensure you retain your rights. Regardless of what causes the ZPIC audit, the process can be complicated and overwhelming.
If you are facing an audit, contact the attorneys at Oberheiden, P.C. at (888) 727-5159 or complete our online contact form today.