If your medical practice, pharmacy practice, medical facility, or other health care business is being audited by a Zone Program Integrity Contractor (ZPIC), you could be facing recoupment and denial of future payments. In order to avoid wrongful recoupments and denials, you need to be smart about dealing with the ZPIC during the audit, and you may need to prepare yourself for the lengthy appeals process.
But, the immediate financial ramifications of an unfavorable audit determination are by no means the only consequences of being targeted by a ZPIC. Zone Program Integrity Contractors also have the ability – and, in many cases, the obligation – to refer providers suspected of Medicare fraud to state and federal authorities.
What Happens After a ZPIC Audit?
You have just been through a ZPIC audit. The auditors found some overpayments, but nothing too substantial, and you think the worst is over. The recoupment amount is not devastating to your practice, and it looks like the auditors might be right, so you are thinking you will pay what the ZPIC says you owe and move on.
Unfortunately, the audit could be just the beginning.
If there is evidence to suggest that you, or one of your employees, either knew about the overbilling or intentionally overbilled Medicare, the ZPIC may refer your case for further investigation – and maybe even civil or criminal prosecution.
Here is a list of just some of the governing bodies and federal agencies who may have access to the results of your ZPIC audit:
- Centers for Medicare and Medicaid Services (CMS) – CMS has investigative jurisdiction over cases of suspected Medicare fraud, and it has been endowed with the authority to impose civil monetary penalties (CMPs) and pursue various other remedies against health care providers suspected of submitting false and fraudulent claims to Medicare.
- Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS) – OIG is the enforcement arm of DHHS, and its mission is, “to protect the integrity of [DHHS] programs as well as the health and welfare of program beneficiaries.” OIG is “at the forefront” of the federal government’s fight against Medicare fraud. OIG also has Medicare Fraud Control Units in 49 states and Washington, D.C., which work with state law enforcement authorities and investigators to pursue providers suspected of fraud.
- Department of Justice (DOJ) – The DOJ is the federal government’s chief law enforcement agency. DOJ investigators aggressively pursue health care providers suspected of Medicare fraud, and the agency’s attorneys vigorously prosecute charges under a variety of federal statutes that directly and indirectly apply to Medicare fraud.
- Federal Bureau of Investigation (FBI) – The FBI investigates individuals and entities suspected of a wide range of federal offenses, including Medicare fraud. FBI agents routinely work with investigators and prosecutors from other agencies to develop and pursue cases against providers suspected of submitting fraudulent reimbursement requests to Medicare and other federal benefit programs.
- Medicare Fraud Strike Force – The Medicare Fraud Strike Force is a joint effort of the OIG, DOJ, FBI, and other authorities, and its sole focus is on identifying and prosecuting individuals and companies suspected of submitting false and fraudulent claims. The Medicare Fraud Strike Force has physical bases in nine locations strategically located around the country, including one in Texas.
- State Licensing Boards – In addition to referring providers to federal authorities, ZPICs can also refer providers to state licensing boards. These boards have the power to take disciplinary action against providers suspected of submitting false and fraudulent claims – up to and including license revocation – regardless of the outcome at the federal level.
Depending on the nature of your case and the agency or agencies that get involved, an unfavorable ZPIC audit determination could potentially lead to civil or criminal fines, treble damages (liability for three times the government’s actual losses), licensing action, loss of hospital privileges, and even federal incarceration. As a result, while the immediate results of a ZPIC audit might be manageable for your business or practice, the potential for further consequences makes it critical for all providers to vigorously defend against unfavorable determinations and, if necessary, appeal the outcome of their ZPIC audits.
Facing a ZPIC Audit? Here is What You Need to Know
At Oberheiden & McMurrey, LLP we bring decades of experience to representing health care providers in ZPIC audits, federal investigations and prosecutions, appeals, and other Medicare-related matters. Our attorneys include experienced health care fraud defense lawyers and former federal prosecutors who have handled significant numbers of Medicare fraud cases with successful results. Our attorneys have prepared these free resources for health care providers facing ZPIC audits in Dallas, throughout Texas, and nationwide:
- What Is a Zone Program Integrity Contractor?
- What Medicare Providers Need to Know About ZPIC Audits
- What Should You Do in a ZPIC Audit?
- Five Mistakes to Avoid in ZPIC Audits
- How to Prevail in ZPIC Audits and Appeals
- Will the Results of a ZPIC Audit Be Shared with Prosecutors?
- How ZPIC Audits Can Result in Government Investigations
Finally, it is important not to overlook one additional entity that has access to the results of your audit: the ZPIC. In addition to seeking recoupments and denying payments as we mentioned above, ZPICs also have the ability to institute prepayment review. This means that your Medicare billings can get held up for months while auditors screen them detail-by-detail to determine whether payment is necessary. While ZPICs do not only conduct prepayment reviews for providers that have already been audited, an unfavorable audit determination makes your business or practice a strong candidate for prepayment review, and it also means that you are on the radar for additional audits in the future.
Oberheiden & McMurrey LLP | ZPIC Audit Attorneys Serving Providers Nationwide
For more information about the risks of ZPIC audits and to inquire about our firm’s representation, please call (888) 680-1745 or contact us online. Our principal offices are located in Dallas, Texas. When you contact us, we will provide you with a free initial case assessment, and we will help you understand the steps you need to take to protect your business or practice.