Health Insurance Forums & FAQ

The Zone Program Integrity Contractors (ZPIC) program, which was designed by the Centers for Medicare and Medicaid Services (CMS), can seek out and act against those that are potentially participating in Medicare or Medicaid fraud. 

The primary goal of this audit is to identify potential abuse, waste, and fraud. It is important to note that ZPIC is not only for fraud. Even waste is something that a ZPIC audit seeks out to avoid unnecessary waste of taxpayer dollars. 

It is also important to recognize that ZPIC contractors are not the same as CMS contractors. 

What Prompts a ZPIC Audit?

A ZPIC investigation will usually start when the provider receives a notification. The review system is not at random; instead, there are factors used to decide which providers warrant a professional inspection. Complaints received and referrals may also prompt audit.

Factors that influence audits include:

• Data Analysis – ZPIC can use data to help identify outliers that require an audit. This can include issuing specific services, billing data, the length of stay compared to national data and so forth. For example, an acute hospital care facility with an unusual number of cases might prompt an audit. Another example is a home health care service with patients having extended visits.
• Complaints – Complaints are made by employees, beneficiaries, and whistleblowers. These claims will almost always trigger a ZPIC audit.
• Referrals – ZPIC may receive referrals to conduct an audit from other contractors, law enforcement, and other federal agencies.

Does ZPIC Have the Authority to Conduct an Audit?

ZPIC does have the authority to conduct inspections. They can identify potential fraud, then make recommendations based on their audit results. The actions they could take if they suspect that your organization is guilty of waste or fraud include:

• Referring cases to law enforcement.
• Submitting the case to CMS for further investigation or to officially remove the provider from the program.
• Conducting a visit to the auditee’s location – without announcement.
• Interviewing staff and management at the facility under audit.
• Requesting all documentation, medical records, and patient charts to assess charges.

Providers are not always warned about an upcoming audit. Instead, ZPIC has the authority to start their investigation and show at the provider's office without notification. In most ZPIC cases, the information comes when the auditor arrives on the scene.

Some Providers are More Prone to ZPIC Audits than Others

ZPIC tends to audit some providers more than others. In fact, the types targeted in 2017 primarily consist of:

• Home health organizations
• Hospice companies
• Pain management services
• Physician offices and private practices
• Ambulance services
• Diagnostic testing facilities
• Clinical laboratories
• Chiropractic offices
• Nurse practitioners

Protecting Your License

ZPIC is serious. ZPIC can refer to have you removed from the Medicare and Medicaid programs, but also revoke your license, which makes it impossible for you to treat your patients or operate. ZPIC does have the authority to audit, and a simple analysis of coding and billing with any errors noted could cost your company its license.

Therefore, it is imperative that you hire an attorney that has ZPIC experience. Your attorney can defend your practice, hire in house professionals to reassess your billing practices, and protect your license.