ZPIC Audits & Overpayment

Zone Program Integrity Contractors (ZPICs), which replaced Program Safeguard Contractors (PSCs), are single-function contractors.  ZPICs are responsible for (1) data analysis and data mining, (2) conducting medical reviews in support of benefit inquiry, (3) supporting law enforcement and answering complaints, (4) investigating fraud and abuse, (5) recommending recovery of federal funds through administrative action, and (6) referring cases to law enforcement.  Because ZPIC audits are commonly related to an investigation of fraud and abuse, it is essential for Medicare providers and suppliers to align themselves with qualified health care attorneys who possess an in-depth knowledge of the Medicare program and a sophisticated understanding of governing federal regulations

Unlike the RAC and the CERT which limit their review only to claims that have already been paid, the ZPIC will audit active claims in order to identify fraud.  When conducting an audit, ZPICs generally perform a database review of a provider/supplier’s Medicare claims.  The ZPICs will compare a provider or supplier’s Medicare billings with that of providers and suppliers of the same type within a designated area.  If the ZPIC suspects fraud or abuse, it may conduct an on-site inspection, request additional documentation, review patient records, as well as interview beneficiaries and providers.

ZPIC audits may result in pre-payment and post-payment claims review, the initiation of administrative sanctions, such as payment suspension, overpayments, provider exclusion; and may even lead a provider/supplier being referred to law enforcement.

At Gaitan Law Group, our attorneys work with Medicare providers and suppliers to prepare and respond to ZPIC audits.  Our clients benefit from our lawyers’  ability to aggressively confront reimbursement and compliance issues throughout the administrative process and judicial proceedings.  Our health care attorneys have developed unique strategies to overcome bureaucratic delays, narrow the scope of the ZPIC audit, ensure that CMS audit procedures are being followed, and lessen the effect of an audit on a Medicare provider or supplier.   

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