What You Need To Know About ZPIC Audits

The Medicare Program is the national program created to ensure the elder and the disabled. Center for Medicare and Medicaid Services are the one responsible to administer the said program. CMS is under the supervision of the Department of Health and Human Services. CMS contracts private companies to administer the Medicare Program.

            Based on the type of work to be performed under the contract, there is a variety of contracts that the CMS provides.

  • ZPICs are contracted by CMS to identify and put a stop to potential fraud.
  • (MACs) Medicare Administrative Contractor administers the Medicare Program.
  • (CERTs) Comprehensive Error Rate Testing Contractors are the ones calculating the Medicare Fee-for-Service improper payment using statistically valid random samples or SVRS.
  • (RACs) Recovery Audit Program Contractors are responsible for straightening improper Medicare payments which are made on a claim for health services provided to the beneficiaries.

Primary Role of ZPICs.

Audits are being performed by MACs, CERTs, and RACs. They are focused on identifying potential errors and take necessary actions in the form of collecting overpayments. However, ZPICs is more powerful compared to the other contractors.  ZPICs primary role is to identify cases of potential fraud, develop it, then take immediate action to ensure the security of the Medicare Trust Fund.

ZPICs are authorized by the CMS to perform analysis of data and medical reviews. They are also allowed to initiate deeper actions like payment suspension or worse, be referred to law enforcement for further investigation for possible civil or criminal prosecution. ZPIC usually do on-site visits for the purpose of an interview with any staff on the provider’s’ location. Then they will request medical records for them to review.

7 Jurisdictional ZPIC zones in the United States.           

These zones are under the watch of the ZPIC in the United States and its territories.

  • Safeguard Services (Zone 1) California, Hawaii, and Nevada
  • Advance Med (Zone 2) Alaska, Arizona, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming
  • Cahaba (Zone 3) Indiana, Illinois, Kentucky, Michigan, Minnesota, and Ohio
  • Health Integrity (Zone 4) Colorado, New Mexico, Oklahoma, and Texas
  • Advance Med (Zone 5) Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia
  • Safeguard Services (Zone 6) Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, and Washington D.C.
  • Safeguard Services (Zone 7) Florida

What Providers Need To Know?

When anyone from your staff is contacted by a ZPIC representative, there are some important things that you need to know. Don’t just give out any important information. Educate yourself and your staff before the inevitable happens. Here are some pointers that any provider should know.

  • ZPICs are not authorized by CMS to conduct provider outreach and education
  • ZPICs are not allowed to perform medical reviews for non-benefit integrity purposes
  • ZPICs perform an audit only for the purpose of identifying possible fraudulent activities to be referred to the law enforcement.
  • ZPICs needs to refer suspected fraud cases directly to HHS Office of Inspector General
  • ZPICs can refer the case to the FBI if the provider is suspected of fraudulent billing on both Medicare and Medicaid; to the Medicaid Fraud Control Unit
  • ZPIC can notify the state licensing agency if the provider is suspected of licensing issues

You need to understand the issues that are important to the law enforcement which makes it also important to the ZPICs. Take the necessary steps to make sure that they are compliant with the requisite rules and regulations so that a ZPIC audit will not lead to severe consequences.