Medicare Audit by Zone Program Integrity Contractor

If you’re reading this article it’s probably because you or your medical office has received a letter from a Zone Program Integrity Contractor (“ZPIC”) for The Centers for Medicare & Medicaid Services (“CMS”) alleging that you may have improperly billed Medicare for the provision Medicare Services to your patients.

 

What is a ZPIC?

There are seven ZPIC zones. It is possible for providers to hear from more than one ZPIC since the seven ZPICs focus on different aspects of the Medicare program. ZPIC Zone 7 includes Florida, Puerto Rico, and the U.S. Virgin Islands in its geographic scope. The Zone 7 – Zone Program Integrity Contractor was established to identify, research, and investigate cases of Medicare Program fraud relating to Parts A and B, DMEPOS, home health and hospice, and claims for dually eligible Medicare and Medicaid recipients.  Fraud may include:

• Billing for services not rendered
• Double-billing or over-billing
• Soliciting, offering, or receiving a kickback or rebate for patient referrals
• Billing non-covered or non-chargeable services as covered.

 

ZPICs responsibilities include reviewing the accuracy and justification of all services reimbursed by the program, and if necessary, take action to ensure any inappropriate Medicare payments are recovered.

Periodically ZPICs are required to conduct reviews of providers to ensure that Medicare claims have been appropriately billed. Occasionally, a ZPIC may determine based on an analysis of your claims data that you may be billing inappropriately for services. Once that determination is made, the ZPIC will begin its investigation to determine whether you have in fact billed inappropriately.

 

How does the ZPIC investigate?

ZPICs may conduct announced or unannounced on-site inspections at which time they will retrieve certain Medicare beneficiary records and other related business records. ZPICs will provide a list of affected Medicare beneficiaries and you will be required to produce documentation that supports the billed services, including, but not limited to:

• All Medical Findings
• Progress Notes
• Doctor’s Orders
• Office Notes
• Operative Reports and Notes
• Patient History and Physical Exam
• Laboratory Test Results
• Radiology Reports
• Billing Statements
• Superbills
• Patient Information Sheet
• Patient Encounter Forms
• Patient Consent Forms
• Advance Beneficiary Notice
• Copy of Beneficiary Card and Photo Identification

 

During or after the on-site visit ZPICs may: (1) interview certain members of your staff; (2) perform a medical review; (3) Determine the need for administrative actions, such as payment suspensions and prepayment or auto-denial edits; (4) interview beneficiaries and/or (5) refer your case to law enforcement.

Law enforcement includes the OIG, FBI, or the U.S. Attorney’s Office. Prior to alerting law enforcement, ZPICs are required to take all other appropriate administrative actions. In some cases, law enforcement agency may not prosecution due to lack of evidence, insufficient, etc.

ZPICs will also look to determine whether the provider received prior audits or provided educational letters in the past by other CMS contractors.

Once the ZPIC has collected and analyzed enough data that has been obtained from the provider, they will determine whether the information indicates billing error or something more sinister such as Medicare fraud, waste or abuse. If ZPICs determine that no fraud has occurred then they will normally treat the matter as an overpayment and close the case. The ZPIC will then refer the matter to the Medicare Administrative Contractors (“MAC”) for further administrative action. Examples of administrative action include the following:

• Educational letters
• Revocation of a provider’s assignment privileges
• Mandatory Prepayment Review or Post-payment Review
• Suspension of Provider Payments
• Referral to State licensing boards and other professional societies.

 

There is a significant chance that one or more of your claims will be audited in the future by a ZPIC. ZPICs have been aggressively reviewing and investigating provider and supplier medical records to identify improper billing and payments. Most providers and suppliers are identified for audit and/or investigation through an analysis of their billing practices. Our firm recommends that you consult with an experienced Healthcare Attorney if you are being audited by CMS’s Zone Program Integrity Contractors or if you have been placed on any type of corrective action. Contact us so that we can create a defense against the allegations while ensuring that you comply with the audit investigation.