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What Is a Zone Program Integrity Contractor?

Zone Program Integrity Contractor
ZPIC Attorney Hotline: 888-680-1745
Oberheiden, P.C.
Former Medicare Prosecutors & Defense Counsel

As part of various federal healthcare reform laws, the Centers for Medicare & Medicaid Services (CMS) became authorized to create special entities called Zone Program Integrity Contractors (ZPICs) to perform program integrity functions. ZPICs are federal contractors who work under the direction of CMS. Currently, seven program integrity zones exist which encompass certain geographic areas. Zone 1 is covered by Safeguard Services (SGS) and includes California, Hawaii, Nevada, American Samoa, Guam, and the Mariana Islands.  SGS also covers Zone 7, which includes Florida, Puerto Rico, and the Virgin Islands. Zone 2 is covered by AdvanceMed and includes Washington, Oregon, Idaho, Utah, Arizona, Wyoming, Montana, North Dakota, South Dakota, Nebraska, Kansas, Iowa, Missouri, and Alaska. AdvanceMed also handles Zone 5:  Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, North Carolina, South Carolina, Virginia, and West Virginia. Zone 3 is covered by Cahaba and includes Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky. Zone 4 is covered by Health Integrity and includes Colorado, New Mexico, Texas, and Oklahoma. Zone 6 is covered by Under Protest and includes Pennsylvania, New York, Delaware, Maryland, Washington D.C., New Jersey, Massachusetts, New Hampshire, Vermont, Main, Rhode Island, and Connecticut.

Zone ZPIC Geographic Area
Zone 1 Safeguard Services California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands
Zone 2 AdvanceMed Washington, Oregon, Idaho, Utah, Arizona, Wyoming, Montana, North Dakota, South Dakota, Nebraska, Kansas, Iowa, Missouri, Alaska
Zone 3 Cahaba Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, Kentucky
Zone 4 Health Integrity Colorado, New Mexico, Texas, Oklahoma
Zone 5 AdvanceMed Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, North Carolina, South Carolina, Virginia, West Virginia
Zone 6 Under Protest Pennsylvania, New York, Delaware, Maryland, Washington D.C., New Jersey, Massachusetts, New Hampshire, Vermont, Main, Rhode Island, Connecticut
Zone 7 Safeguard Services Florida, Puerto Rico, Virgin Islands

ZPIC Audits Investigate Fraud

Some of the program integrity functions include medical review, cost report auditing, data analysis, and provider education. ZPICs are responsible for reviewing the accuracy and justification of services reimbursed by a federal healthcare program. The ZPIC must ensure the correct amount has been paid for covered services rendered to eligible beneficiaries by legitimate healthcare providers. The primary goal of a ZPIC is to detect and investigate fraud, waste, and abuse in an effort to ensure that Medicare Trust Fund money is not inappropriately paid.

Common Findings of ZPIC Audits

Among other things, a ZPIC may investigate a healthcare company for (1) billing for services not rendered, (2) duplicate billing, (3) soliciting, offering, or receiving kickbacks for patient referrals, or (4) altering claims or records to obtain higher reimbursement rates. Importantly, information and evidence of suspected fraud or abuse obtained by a ZPIC can be turned over to the Office of the Inspector General (OIG) or Department of Justice (DOJ) for civil or even criminal prosecution. It should, therefore, go without saying that dealing with ZPIC investigations is a serious matter that requires the best federal defense attorney who can handle the case with the utmost care, professionalism, and expertise.

Experienced Attorneys Can Help Your Business

Oberheiden, P.C. offers the expertise and first-hand knowledge of numerous attorneys and law enforcement personnel that have previously overseen ZPIC audits on behalf of the government. These attorneys bring insights to the table and are able to share with our clients what to do in an audit and how to deal with the auditor. More importantly, our attorneys are able to prepare Medicare providers for follow up audits and government subpoenas if the audit production fails to meet government expectations.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden

Founder

Attorney-at-Law

John W. Sellers
John W. Sellers

Former Senior Trial Attorney
U.S. Department of Justice

Local Counsel

Joanne Fine DeLena
Joanne Fine DeLena

Former Assistant U.S. Attorney

Local Counsel

Joe Brown
Joe Brown

Former U.S. Attorney & Former District Attorney

Local Trial & Defense Counsel

Amanda Marshall
Amanda Marshall

Former U.S. Attorney

Local Counsel

Aaron L. Wiley
Aaron L. Wiley

Former Federal Prosecutor

Local Counsel

Roger Bach
Roger Bach

Former Special Agent (OIG)

Gamal Abdel-Hafiz
Gamal Abdel-Hafiz

Former Supervisory Special Agent (FBI)

Chris Quick
Chris Quick

Former Special Agent (FBI & IRS-CI)

Kevin M. Sheridan
Kevin M. Sheridan

Former Special Agent (FBI)

Ray Yuen
Ray Yuen

Former Supervisory Special Agent (FBI)

Dennis A. Wichern
Dennis A. Wichern

Former Special Agent-in-Charge (DEA)

Medicare and Medicaid providers that are facing a government audit, ZPIC audit, or other forms of healthcare investigation should contact the experienced attorneys of Oberheiden, P.C. for a free and confidential consultation. We are also available on weekends.

888-680-1745
Including WeekendsOberheiden, P.C.
Compliance – Litigation – Defense
888-680-1745
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Not all attorneys of Oberheiden, P.C. are licensed in California and nothing contained in here is meant to constitute the unauthorized practice of law.

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