ZPIC Audits

Understanding the Importance of Professional Guidance

As a health care provider, there's a lot that goes into preparing for and responding to Zone Program Integrity Contractors (ZPIC) audits. It's a process that cannot be taken lightly because the potential consequences are too great. It's important that you don't make the mistake of trying to respond to a ZPIC audit on your own, but instead leverage the expertise of qualified counsel. This is especially important as it relates to understanding the function and goal of ZPICs as contractors of the Centers for Medicare and Medicaid Services (CMS).

Common Errors and Risks

There are often errors made during the process of health care providers trying to handle a ZPIC audit. Some of the dangers include responses that are either incomplete or inaccurate. The priority for your initial response should be accuracy and completeness, making sure appropriate explanations are provided where required or necessary. There have been many changes in related laws, which is just one of the many reasons why an experienced attorney should be involved in the audit.

ZPIC's Role and Why Audits Happen

Since the job of ZPIC is to handle functions that were once handled by Medicare regional carriers, there have been audits that are purposed to identify fraudulent activities and overpayments. In the event that you receive a letter from a ZPIC regarding the Medicare Program with a request to audit your business, it would be prudent to contact an attorney immediately for guidance. As a result of budget deficits, there has been pressure in recent years for states to recover funds related to Medicaid programs. The unfortunate outcome has been a much higher number of Medicare and Medicaid audits than ever before conducted by ZPIC.

Goals and Focus Areas of ZPIC Audits

Often the goal of a ZPIC audit is to recover money from health providers, such as dentists and physicians on behalf of the government, both federal and state. An experienced attorney will understand associated laws and ensure all documentation is completed with the highest level of caution and prudence. There are some areas that are scrutinized more closely than others and it can be difficult for health care providers to understand which issues are of particular interest to auditors. The extrapolation of perceived overpayment is an issue that could result in the assessment of fines, as well as repayment.

How the Audit Process Works

The way a ZPIC audit often works is that a letter is sent to your practice just before your office closes for the day. The letter will inform you that an audit or site visit of your practice may be scheduled. There's a chance that the audit will occur somewhere other than your main office. The actual audit is quite extensive and will often involve inspecting credentials, rooms and equipment throughout the premises. The will also take pictures and request copies of important documents. The copies requested may include information about procedures, treatment protocols, policies and patient records. They will also examine inventories an invoices related to medications.

Follow-up and Repayment

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After the audit has taken place, there's a good chance that you will receive a follow-up notice and a request for additional information. Depending on the circumstances, you may be asked to repay overpayments at that juncture. There is significant value in having counsel available immediately upon receiving a notice of audit. You'll need someone to help you navigate the process and provide direction during what can feel like an overwhelming situation. In some states, if overpayment is identified by an audit related to Medicaid, there is only a 30 day window provided to repay the funds. There have been instances where statisticians were hired to review the findings of a ZPIC audit based on the recommendation of counsel. In one case, errors made during the audit were found, which saved the health care provider tens of thousands of dollars.