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What a ZPIC Audit Means for Your Medical Practice

July 22, 2020

ZPIC audits may sound intimidating and for good reason. During a Zone Program Integrity Contractor (ZPIC) audit, auditors investigating fraud can request any documentation, make as many on-site visits, or conduct as many interviews as they like.

ZPIC audits were created as a result of the Medicare Modernization Act. The Centers for Medicare & Medicaid Services (CMS), the government agency responsible for preventing healthcare fraud, conducts Zone Program Integrity Contractor audits with increasing frequency.

After healthcare legal reforms, CMS created seven geographically-based program integrity zones, each overseen by a ZPIC. ZPICs report to the Center for Program Integrity (CPI) and administer program integrity functions to ensure that Medicare funds are used properly.

According to Section of the Medicare Program Integrity Manual (MPIM), titled the “Identification of Potential Exclusion Cases,” ZPICs review cases to determine if there is a reason to take exclusionary action. Common audit triggers include patterns of audit findings, previous convictions, frequent claim reviews, and excessive claim submissions.

What Should I Do to Prepare for a ZPIC Audit?

You’ll know you’re being audited when you receive an audit notice or a document request from the contractor performing your audit. If this happens, it means fraud or abuse is suspected. The best way to achieve a positive outcome is to prepare as much as you can.

  • First, prepare your paperwork. As much as possible, document everything you can. You may want to assign a staff member to verify, inspect, and organize documentation. Pay special attention to your coding and billing documents, since these are often targeted by auditors.
  • Second, prepare your compliance plan. Ideally, your practice already has a current one, but scrutinize yours carefully for updates, relevance, and thoroughness.
  • Third, prepare your staff. Conduct a mock audit if possible. Help them understand what to expect from an audit — what evidence they are expected to provide, how long the audit may take, and what the results could mean for your healthcare practice.

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ZPIC Audits Can Lead to OIG Exclusion

If the ZPIC decides your healthcare entity should be excluded, they make a recommendation to the Office of the Inspector General (OIG). The contractor may or may not notify you of this decision. A provider who is excluded by the OIG can no longer receive federal payment for health services. Alternatively, the ZPIC may also demand Medicare repayment from the provider.

In either case, the process may be appealed. Due to the complexity of this aspect of healthcare law, however, it’s usually a good idea for a healthcare provider considering a ZPIC appeal to hire legal counsel.

ZPIC audits help prevent fraud but can lead to exclusions and other disastrous consequences for your healthcare entity without the proper compliance program in place. Learn more from Verisys about how you can ensure your providers meet all government and regulatory standards to mitigate the risk of OIG exclusion.

Juliette Willard Written by Juliette Willard
Healthcare Communications Specialist
Being creative is my passion! Writer. Painter. Problem Solver. Optimist.
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