What to Do if You Get a ZPIC Demand Letter Without a Record Request

zpic demand letter

If you get a ZPIC demand letter without a record request that means you’ve been the subject of an automatic review. Automatic reviews are implemented in order to detect obvious mistakes in billing. They’re usually done by computer and are typically fairly simple to handle. The good news is, you might not have to do anything further.

However, in order to ensure you address any concerns and requests thoroughly, you’ll want to let an experienced lawyer take a look at your demand letter. Otherwise, here’s a brief explanation of what you can do if you receive a demand letter that is not accompanied by a record request.

Review Your Records for a Mistake

Make sure you fully understand the reason why the claim or claims were flagged in the review. Go back over your own records to look for the mistake. This step is especially important in addressing the demand letter and preventing your business from facing costly consequences. Review your records thoroughly. If you aren’t sure what to look for in reviewing your documentation, consult one of our attorneys.

Find Out Why the Overpayment Was Made

Common reasons why overpayments are flagged in an automatic review include:

  • The service provided cannot be covered by Medicare or Medicaid.
  • The service is “medically unbelievable,” meaning that it doesn’t make sense from an anatomical standpoint, or is medically unreasonable.
  • You have failed to respond to a record request for a previous, complex review in a timely manner.

There could be a number of other reasons an overpayment was made so make sure you track down exactly what might have happened.

Decide Whether You Want to Appeal

Do you want to appeal to the findings? Talk to your attorney about whether an appeal is the best decision for you. Appeals can be time-consuming and costly, but having a history of claim denials can make you more vulnerable to future audits.

Take Action

You’ll need to take corrective action right away to fix your mistake and keep your organization from attracting any more scrutiny. If you are not appealing the decision, pay the overpayment. A payment plan may be possible, or you may be able to get some of the debt forgiven.

Contact Experienced ZPIC Attorneys at Oberheiden, P.C.

Getting a ZPIC demand letter can be scary and intimidating, especially if you aren’t sure what to do next. Our attorneys have the experience and knowledge you need to help you navigate the ZPIC audit process, and figure out the best way for you and your business to proceed. Don’t risk making a costly mistake attempting to navigate the process alone, or even worse, ignoring the letter you have received.

To learn more about a ZPIC audit and what you can expect whether or not documentation is requested you can speak with one of our attorneys at Oberheiden, P.C.. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.

Possible Consequences of a ZPIC Audit

ZPIC audits

Coming under the fire of a ZPIC audit can have a variety of consequences for health care providers. Although some of the consequences are more severe than others, a ZPIC audit has every potential to destroy your business forever. To give you a small idea of what might be at risk, the following are some examples of actions that might be taken against a medical practice or provider after the initial probe audit is undertaken by the ZPIC.

Post-Payment Audit

As the name suggests, these ZPIC audits are conducted on Medicare claims that have already been paid out by the government. Unfortunately, in many cases, the ZPICs in charge of conducting these audits tend to apply a strict application of the applicable regulations. Any deviation from them, regardless of how minute or inconsequential, is treated as being suspect. This often results in a failure to comply with every single requirement, significantly increasing the amount the government allegedly overpaid.

Pre-Payment Audit

While a post-payment audit focuses on claims already paid, a pre-payment audit targets claims that a provider is attempting to collect on after providing a service. A pre-payment audit is particularly troublesome for a couple of reasons. Because the services, equipment, and staff time have already been used to provide treatment to the patient, the provider must endure an added layer of payment red tape. The pre-payment audit process can become significantly backlogged to the point where it places a medical practice in jeopardy of not being able to pay its bills on time.


ZPICs have the power to initiate actions that are designed to suspend the ability of a medical provider to be reimbursed for the Medicare services rendered. Given the uncertainty of the status of health care insurance, it’s expected that suspensions will continue to grow.


Like other aspects of the ZPIC audit process, revocations seem to hinge on the whim of the particular ZPIC that is assigned to a facility. A revocation might occur from slights as simple as being deemed “uncooperative” when a ZPIC was on site, or failing to properly give notice of a move to Medicare .

ZPICs also have the authority to refer medical professionals to the Department of Justice for criminal and civil charges. When a ZPIC audit is getting underway, no one can predict how it will turn out. Seeking out a qualified attorney early in the process provides necessary safeguards.

Contact Experienced ZPIC Audit Attorneys Today

Even if you believe you’ve managed your business exactly as you should, a ZPIC audit can have dire consequences. Because of the costs and the damage to your reputation that can come with an audit, you also risk losing your income and business completely. If you are being audited or you need help appealing, our attorneys have the experience and skills to help you through the process. Contact the attorneys at Oberheiden, P.C. at (888) 727-5159 or complete our online contact form today.

Top ZPIC Audit Targets

ZPIC audit targets

As time goes on, the rate of investigations into Medicare fraud is only expected to increase. ZPICs are making an effort to root out all levels of fraud from the obvious to the subtle, and that has some health care providers wondering if they may find themselves targeted in the near future. The best way to protect yourself from an audit is to follow all guidelines to the letter and have a ZPIC lawyer monitor your facility. If you’re wondering what types of facilities might be more at risk, here’s a list of some of the top ZPIC audit targets.


Because hospices largely focus on the patient’s needs minute-to-minute, patient treatment protocols can change rapidly. Unfortunately, even if a facility judges that a patient requires a certain procedure or medication, it doesn’t mean Medicare will agree. ZPICs have investigated hospices for what some consider “going too far” with comfort care and other treatments that Medicare deems “unnecessary.”

Home Health Care Companies

ZPICs focus on home health care companies because there is so little public oversight into how they operate. While the vast majority of companies are legitimate and follow the rules, recent reports have indicated an increased rate of fraudulent billing in certain states. This fact increases the risk for ZPIC audits for home health care companies.

Private Practices

Like home health care companies, private physician practices are also responsible for their own individual oversight. The reasons for an increased ZPIC audit rate, unfortunately, aren’t as clear. A small number occur because ZPICs are required to audit a random selection of approximately 120,000 practices, while the rest occur after abusive or fraudulent billing claims.

Diagnostic and Testing Facilities

Diagnostic and testing facilities have an increased rate of ZPIC audits because of the nature of the work they do. All providers are required to justify diagnostic tests, and this includes facilities, too. If a facility cannot provide proof that the patient required a test expressly, ZPICs may view it as abuse of the Medicare system. This includes unnecessary MRIs, blood tests, CAT scans, and ultrasounds.

These are just a few of the most common top ZPIC audit targets. Many other providers have an increased risk too. Always remember that it is possible to be randomly selected for an audit. If you are a provider who has recently received an audit notification, contact a ZPIC lawyer immediately.

Experienced ZPIC Audit Attorneys of Oberheiden, P.C.

The truth is, any medical facility is at risk of being audited, sometimes for something as small as a numerical error. Unfortunately, an audit can turn your business upside down and completely destroy everything you have built. If you are at risk of being audited, you have a better chance at a positive outcome if you have qualified and experienced counsel to represent your best interests.

Let us help you and your business through a ZPIC audit in the best way possible. Contact the attorneys at Oberheiden, P.C. at (888) 727-5159 or complete our online contact form today.