What Happens in the ZPIC Audit Appeals Process?

ZPIC audit

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 ensuring 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.


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 assumptions 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.


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 of 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, P.C. at (888) 727-5159 or complete our online contact form today.

What to Expect from ZPIC Audit Protocol

ZPIC audits

Audit candidate selection is rarely a result of random chance. They base their choice on statistical anomalies or inconsistencies in the accused health care provider’s records and activities. A ZPIC audit may also result from employee complaints or referrals by government and law enforcement entities. Although ZPIC has a high amount of discretion in their investigation, they must still follow certain protocols.

ZPIC Timeline

There is a typical timeline that comes with an audit. Although the order may vary depending on ZPIC’s discretion, there is always an initial inspection and follow-up requests for additional information.

ZPIC will request medical records and all business-related documentation which may include patient reports. The provider must fulfill these requests within 15 days. ZPIC can request additional records and clarifications as many times as they see fit. There is no limit to how many requests they can make or on how long they may continue their investigation.

Then, an initial visit by ZPIC inspectors will take place. These visits may be unannounced and law enforcement officials may accompany ZPIC if they deem it necessary. They may also interview employees during their visit. It’s recommended to provide legal counsel during these interviews. The health care provider must arrange this before an audit takes place. ZPIC may require the case to escalate to other law enforcement agencies.

Statistical Analysis and Extrapolation

Although it might seem complicated, a ZPIC audit can include statistical analysis and extrapolation techniques as part of their investigation. ZPIC may do this if they find a “sustained or high level of payment error” in the health care provider’s records. ZPIC does not clearly define this “payment error” due to their broad scope and the discretion available for their investigations. This broad scope can be used by the defendant since it is subjective.

ZPIC must provide clear explanations to the defendant if they decide to use statistical extrapolations in their investigation. They must also disclose why the review is happening, the time frame under review, and the appropriate medical record and other documentation to support ZPIC’s claims. They must also reveal the location where the review will take place, explain how they will release the results to the public, and the potential methods of financial reclamation ZPIC may impose on the provider.

Because the many facets of a ZPIC audit can be complicated, including the protocol that ZPIC themselves must follow throughout the process, you can’t afford to navigate the process alone. An experienced attorney can help you with the ZPIC audit while you focus on managing your business.

ZPIC Audit Attorneys with Experience at Oberheiden, P.C.

Although there is certain protocol that a ZPIC audit must follow, it doesn’t always happen. This is just one of the reasons you need an experienced attorney on your side to make sure you retain your rights throughout the process. If you are being audited or need help with an appeal, don’t panic. Contact the attorneys at Oberheiden, P.C. at (888) 727-5159 or complete our online contact form today.

What Happens After a ZPIC Audit?

ZPIC audits

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, P.C.

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, P.C. 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.

How to Prepare for a ZPIC Audit

ZPIC audits

If you’re facing a ZPIC audit, you probably aren’t prepared. Many people think if they aren’t doing anything wrong, they don’t have to worry about an audit. However, most health care organizations come under scrutiny at some point or another whether it’s because of fraud or even a small error. As a result, it’s important to prepare for an audit even if you don’t think you will ever face one. Here are a few ways you can prepare for auditing and protect your practice and staff.

Have Legal Counsel on Hand

One of the best ways to prepare for an audit is to be ready with an experienced attorney to support you in the case of any legal problem, including ZPIC audits. If you do have an audit, you can arrange to have your attorney with you during the auditing process. Good legal counsel can have your back in stressful times and help you retain your rights throughout the process.

Have a Compliance Plan

According to the Affordable Care Act, medical providers should create a Compliance Program adhering to government regulations. If you don’t yet have one in place, it’s important that you set it up as soon as possible. Review your documents and requirements, implement the program, and make sure your staff understands and complies with the program once established.

Keep Documents Up to Date

Make sure your documents are all up to date, including all records, licenses, and certificates you have for your practice. Keeping everything legitimate, updated, and honest can save you from future complications. You can make a better impression with an auditor by showing that you are organized, with all your information correct, and ready when needed.


Verify with the Auditors

If you ever do end up scheduled for a ZPIC audit, it is important to contact the audit team as soon as possible. Make sure to confirm the date and time of the audit, as well as provide them with any necessary preliminary information about the location.

Be Prepared to Tell the Truth

When dealing with auditors, giving misinformation can be a dangerous road to take. Rather than risk getting caught in a lie or withholding information, be completely honest with the auditors. Give truthful information when you are asked a question. If you don’t have the answer, it’s safer to admit to it rather than make a guess. This is an area your attorney can help you with, even before you speak with the auditor.

The auditing process can be long and nerve-wracking for medical providers. However, with some careful planning and extra effort, some of that tension can be eased. Despite the pressures of business and legal matters, you can protect your practice and your staff by making the most of it.

Experienced ZPIC Audit Attorneys

Don’t make the ZPIC audit more difficult for yourself and your business than it needs to be. You don’t have to navigate the process alone. If you are being audited or need help with an appeal, contact the attorneys at Oberheiden, P.C. at (888) 727-5159 or complete our online contact form today.

What Exactly is a Zone Protection Integrity Contractor (ZPIC)?

ZPIC Audits

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, P.C.

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, P.C. at (888) 727-5159 or complete our online contact form today.

What You Need to Know About ZPIC Audit Formats

ZPIC Audits

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

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 Audits

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.

Complex Audits

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.

The Importance of Records in an Audit

ZPIC Audits

A Zone Program Integrity Contractor (ZPIC) performs an audit of medical professionals on behalf of the Centers for Medicare and Medicaid Services (CMS). The primary goals of these ZPICs is to identify cases of suspected Medicare and Medicaid fraud, take action to stop the fraudulent behavior, and recoup any misappropriated funds paid out to them. This is accomplished with the use of audits that look for inconsistencies and outright abuses of the system.

Who Gets Audited by the ZPICs?

One of the most troubling aspects of this program is that a company doesn’t know they are going to get audited. The process of picking a particular business to audit is one that is completely random. This is just one of the reasons it’s important to keep impeccable records, so there are no questions should your business be chosen to be the recipient of a ZPIC audit.

What ZPICs Are Looking for While Investigating

Although it would seem that investigating and looking for fraudulent activity might be simple enough, this isn’t all there is to a ZPIC audit. When a ZPIC audits your records, he or she is evaluating the information available to ensure that the submitted service record was provided to the person stated. The ZPIC must also make the determination of whether the service was necessary and medically reasonable. As the ZPIC searches through your medical records, he or she will be verifying that the diagnosis matches the patient’s gender, age and the procedure performed.

Potential Fraud Red Flags

As the ZPIC combs through your records, missing pages, erased notes, late entries, and pages that seem to be randomly inserted are noted. If these types of inconsistencies are found in the records, it could be an indication of waste, abuse, or fraud. Even if there is no evidence that fraud exists, a ZPIC could conduct a series of reviews that could include requesting additional documentation to support a claim. It could also perform telephone interviews with those patients who were beneficiaries of the claimed services, search for evidence of past complaints or questionable behaviors, perform data analysis of relevant figures, or investigate in many other ways.

If your business received notification that it is the subject of a ZPIC audit, you probably have many questions including whether or not your medical records will pass his or her scrutiny. An attorney experienced in ZPIC audits can help protect your rights and make sure your business has a qualified legal team throughout the process.

Experienced ZPIC Audit Attorneys Can Help

Even if you think you haven’t done anything wrong or you feel as though all your records are in order, you have a lot at stake if you face a ZPIC audit. An audit is a serious matter and even small errors can cost you thousands of dollars in penalties. Don’t risk your business and finances by attempting to navigate an audit alone. Contact the attorneys of Oberheiden, P.C. at (888) 727-5159 or complete our online contact form today.

Red Flags That Could Result in a ZPIC Audit

ZPIC Audit

For many people, it’s assumed that if you don’t do anything wrong, you don’t have anything to worry about. However, when it comes to ZPIC audits, this isn’t always the case. You could inadvertently make a mistake or do something wrong that ends up being costly.

It’s expected that health care expenditures will reach the $4.35 trillion mark by 2018. Of that amount, the Federal Bureau of Investigations (FBI) and the Office of Inspector General of Health and Human Services estimate that as much as 10 percent of those payments could be fraudulent in some way. Here are some of the red flags that could lead to a ZPIC audit.

Living in Certain Areas

Believe it or not, you could be more likely to be audited for simply living in a certain state. The Centers for Medicare & Medicaid Services (CMS) has designated several regions of the country as high-risk areas. If you practiced medicine in these areas in the past or if you do so currently, you might be at higher risk for an audit than other health care providers. These areas include Dallas, Los Angeles, Miami, New York, Detroit, and Houston.

You Aren’t Getting Documentation Upfront

Cutting corners and not getting the right documentation prior to performing a treatment or surgery sets you up for an audit. Even if you aren’t doing anything else that could raise suspicions, something as simple as a patient whose paper trail leads to you as a referral from another health care provider who happens to be getting audited, could bring your practice under fire.

You Attempt to Get Documentation After the Fact

It’s understandable that medical professionals are busy. Part of growing your practice is trying to see as many patients as possible during your open hours. Because the processing of these patients, especially new ones or those who need specialized treatments, can cause a backlog, you and your front office staff could resort to getting the proper documentation at a later date. While this practice is common, it isn’t a good one to get into the habit of performing on a regular basis. Attempting to backtrack and get documentation for a service that you’ve already performed could raise red flags that signal fraud to auditors.

Billing for the Maximum Amount

If your practice is in the habit of always billing for the maximum allowable amount for a certain product or treatment, your chances of an audit are going to increase. The same is true of those codes that are among those that are most often reimbursed by Medicare.

If you see yourself in any of the four scenarios, get prepared. You might need to speak with an attorney with ZPIC experience now before you get audited.

Contact Experienced ZPIC Audit Attorneys Today

Don’t panic. If you are being audited or need help with an appeal, the attorneys at Oberheiden, P.C. can help. Call us at (888) 727-5159 or complete our online contact form today.