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.
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.