What Is a Zone Program Integrity Contractor?
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 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 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 the 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 expectation.
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.
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