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Dr. Nick Oberheiden
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Aaron Wiley
Former State &
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S. Amanda Marshall
Former U.S. Attorney

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The Growing Threat of Zone Program Integrity Contractor (ZPIC) Audits

Categories: Health Care Law

Health care providers face immense scrutiny for allegations of fraud and abuse in the current regulatory climate. Consequently, they encounter significant threats to their future business viability, including recoupment and civil/criminal penalties, when undergoing audits conducted by the federal government. It is essential that you as a healthcare provider, servicing the Medicare market, fully understand the auditing process and respond correctly when undergoing an investigation. At Oberheiden, P.C., we have a dedicated health and medical legal team with proven experience representing physicians and health-care providers in all aspects of Medicare and Medicaid fraud defense. To schedule a free and confidential case consultation with one of our experts, please call (888) 519-4897 or contact us online.

What Are ZPICs?

Zone Program Integrity Contractors (ZPICs) are entities contracted by the Centers for Medicare and Medicaid Services (CMS) to investigate suspected fraudulent activity or identity fraud within the Medicare industry in addition to prosthetics, orthotics, supplies, and home hospice services. Depending on what region your practice operates in, ZPICs may be referred to by different names including: Safeguard Services (SGS), AdvanceMed, Cahaba, Health Integrity, or Under Protest. Although ZPIC audits are somewhat comparable to Recovery Audit Contractors (RACs), ZPIC investigations have the added potential implication of federal Medicare fraud charges, which can result in severe administrative penalties and criminal sentences. This makes it even more important to consult a confident healthcare attorney as soon as possible when encountering matters associated with ZPICs.

What Entities Are Targeted by ZPICs?

A concerning aspect of the ZPIC regulatory structure is that a business has little to no warning they are going to be subjected to an audit – which is why it is of utmost importance to maintain detailed records in case your practice is chosen for a random ZPIC review. A typical ZPIC audit consists of a thorough evaluation of all available information to confirm the veracity of the service record a health care provider submitted in order to determine whether the service was medically necessary and reasonable under the given circumstances.

It’s a common misconception that, if you don’t actively engage in intentional misconduct, then you have nothing to be concerned about when it comes to a ZPIC audit. However, inadvertent mistakes or careless record-keeping errors can result in costly administrative penalties, license revocation, or criminal charges. Conducting business in certain areas that the CMS has designated as ‘high risk’ (including Dallas, Los Angeles, Miami, New York, Detroit, and Houston) may make it more likely your practice will be audited by a ZPIC.

Potential ZPIC Audit Red Flags

During the audit process, ZPICs conduct an in-depth review of your records for missing pages, erased notations, late or inconsistent entries, and pages filed out-of-order. ZPICs could deem such errors as indications of waste, abuse, or fraud, which could trigger a series of subsequent reviews consisting of time-consuming and inconvenient requests for additional documentation to support a claim. ZPICs can also conduct follow-up interviews with those patients who were beneficiaries of the claimed services, search for indications of previous complaints or suspicious conduct, or perform data analysis of business dealings.

All medical practices (especially those servicing patients in CMS ‘high risk’ areas) need to ensure they are implementing responsible business practices to mitigate the risk of ZPIC audits. This includes requesting and filing all requisite documentation from incoming patients prior to performing any treatments or surgeries. Attempting to completely process new clientele after the fact increases the risk of backlogs, errors, and inconsistencies that could lead to a ZPIC investigation. Additionally, if your practice consistently attempts to bill for the maximum allowable amount for a given procedure or service, your risk of being targeted by ZPICs increases significantly.

Through years of experience assisting clients with ZPIC matters, the Oberheiden, P.C., legal team can assist you in implementing a proactive culture of ZPIC compliance internally, within your organization, to protect your business and employees. We can provide you with a customized ZPIC compliance plan to ensure you’ll be adequately prepared when undergoing an audit, including educating staff on applicable regulations, outlining sound records management protocol, and suggesting effective communication and training methodologies.

If your practice was notified of an impending ZPIC audit, you need to understand the process, including whether or not your medical records are sufficient to avoid negative and lasting regulatory consequences. The knowledgeable and experienced attorneys at Oberheiden, P.C., can ensure your rights are protected and that your business is adequately prepared during all stages of the audit process. The risks are simply too great for you to attempt to navigate the lengthy and complex ZPIC system on your own. Contact our dedicated healthcare legal team at (888) 519-4897 or complete our online contact form to receive a free confidential analysis of your situation.

Demystifying ZPIC Audit Formats

The ZPIC auditory regime is complex and specialized. Understanding the different types of audit formats the majority of audits are categorized as and which ones are applicable to your specific business operations is just one of the essential steps in successfully navigating the process that Oberheiden, P.C., can assist you with. Here’s a brief overview of the three main audit formats and the potential implications of each.

  • Automated Audits

Automated audits are generally the result of random annual audit quotas as opposed to specific allegations of fraud or abuse. These types of audits usually don’t consist of highly detailed information requests. Instead, the ZPIC will review the information your practice has already submitted. Although the risk of regulatory action emanating from an automated audit is low, it can still happen. If you find yourself undergoing a random audit, it is important that you anticipate and prepare for a possible appeal by working with one of our experienced ZPIC audit lawyers.

  • Semi-Automated Audits

Semi-Automated ZPIC audits could be the result of either a random selection or evidence of a potential payment issues. Regardless of the initiating trigger, semi-automated audits are computer-generated reviews accompanied by a request for records and billing documentation – which you should have thoroughly reviewed and prepared by a knowledgeable healthcare attorney prior to submission in order to reduce the risk of future issues.

  • Complex Audits

If a ZPIC auditor or Medicare Administrative Contractor (MAC) identifies a specific issue related to your practice, it may conduct a complex audit. This is the most intensive audit format and will likely consist of a request for extensive evidence of the given claim’s necessity and eligibility as well as the legitimacy of the protocol that was utilized. Usually, a complex audit indicates that the ZPIC or MAC has already detected a pattern of fraud or abuse associated with your business dealings. Due to the high risk associated with this type of audit, it’s best to first consult a ZPIC audit lawyer for assistance in responding to the contractor.

Regardless of the audit format you are facing, our knowledgeable and informed legal team stands ready to assist you during all stages of the process. Oberheiden, P.C., proudly offers the requisite experience to ensure your rights are protected throughout the complex auditory scheme. If you are facing an audit, contact us today at (888) 519-4897 or complete our convenient online contact form.

ZPIC Audit Aftermath: Mitigating the Consequences of Regulatory Action

If your practice has been subjected to a ZPIC audit that resulted in a finding of fraudulent or erroneous Medicare or Medicaid claims, you may be faced with the challenge of reimbursing any associated overpayments – which can be substantial, depending on how the amount is determined. Fortunately, there is a possibility that you can reduce or even completely eliminate that debt. The seasoned legal team at Oberheiden, P.C., will conduct a prompt and specialized review of your case to determine:

  • Whether the ZPIC submitted complete and accurate information supporting its findings
  • Whether the ZPIC reviewed your documentation correctly and to the applicable standards
  • Whether the audit required external clinical expert or physician input, and if so, whether the ZPIC obtained it
  • Whether the ZPIC has a history of auditory errors

Based on the results of our findings, we will be able to intuitively advise you regarding the next steps you should take in appealing the results of your ZPIC audit and potentially reducing or eliminating the amount you owe. The dedicated legal team at Oberheiden, P.C., have years of experience in devising effective litigation strategies specifically tailored to your unique circumstances. We understand that dealing with any aspect of a ZPIC audit can be confusing and overwhelming for even the most sophisticated and established practitioners. Fortunately, you do not have to face the daunting prospect of federal investigation alone; our qualified and attentive attorney network can assist you in managing an overpayment scenario.

To learn more about ZPIC audits, overpayment implications, and appeals, contact one of our experienced attorneys at Oberheiden, P.C., today for a free and confidential case analysis via our online contact form or by calling us at (888) 519-4897.

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