CMS Woes: Zone Program Integrity Contractors (ZPICs) Criticized for Oversight in Fraud Investigations

George IndestBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Zone Program Integrity Contractors (ZPIC) are private companies or business entities, that have contracted with the Centers for Medicare and Medicaid Services (CMS). Their purpose is to carry out certain functions related to auditing for possible fraud, that Medicare regional carriers (now called Medicare Administrative Contractors or “MACs”) performed in the past. They are specifically charged by CMS to data mine, identify, and investigate potentially fraudulent behavior in Medicare providers.

Because of this, health care providers that receive a letter from the ZPIC often see it as a potential death sentence, and certainly an eye-opening event, because it involves investigating for fraudulent activity. However, in recent years CMS has been criticized about its oversight (actually, lack of oversight) of these fraud-detection contractors.

Taking a Closer Look at the ZPIC.

ZPIC audit letters are required to comply with regulations and guidelines established by CMS when it comes to making additional documentation requests (ADRs) for pre-payment and post-payment reviews, initiation of Medicare suspension of payments and other areas for which they have authority to investigate under the direction of CMS.

Studies have found many failures of their obligations to comply with guidelines and regulations adopted by CMS and the Department of Health and Human Services (HHS). There has been so much concern over their borderline “unethical behavior” and violations of Medicare regulations that the United States Senate Committee on Finance, as well as the Office of the Inspector General (OIG) of HHS, have both issued scathing reports on them. These reports often warn against what they see as destructive and harmful behavior toward physician practices and smaller medical businesses.

In 2012 a report was issued at the request of the Senate Finance Committee and included the following quote: “CMS and its contractors often cultivate an environment of mistrust and suspicion that all providers of certain services are inherently fraudulent. The sentiment is widely shared by anyone that has worked with CMS contractors in the area of program integrity and a similar environment is probable within the CMS Program Integrity Group. This type of environment leads investigators, contractors, and CMS to pursue providers in an aggressive manner, sometimes unfairly, based on little evidence or collaboration of any wrongdoing.”

According to the OIG: “Often the ZPIC contractors have had no experience in the areas of fraud and abuse for which they should be accountable. The result is a loss to CMS of fraud and abuse funds and providers, many of which are small – medium sized businesses, are forced to spend thousands of dollars to address unfounded audits and investigations.”

To read the OIG report to Congress in full, click here.

Make sure to visit our website’s ZPIC articles and documents section to learn more.

What To Do If You Are Notified of a ZPIC Audit.

When a physician, medical group or other health care provider receives a notice of an audit and site visit from a ZPIC, things happen fast with little opportunity to prepare. A ZPIC will routinely fax a letter to the practice shortly before the end of a business day the day before a site visit/audit to that practice. Auditors will request to inspect the premises, will photograph all rooms, equipment, furniture, and diplomas on walls. They will usually request copies of several patient records to review later. They will request copies of practice policies and procedures, treatment protocols, all staff licenses and certifications, drug formularies, medications prescribed, and medications used in the office. ZPIC auditors will inspect any medication/narcotic lockers or storage cabinets and will request drug/medication invoices and inventories. You will usually be contacted for follow-up information and documentation after the audit and will eventually be provided a report and, possibly, a demand for repayment of any detected overpayments.

For a checklist on what to do after you receive initial notification of a ZPIC audit, read our two-part blog. Click here for part one and click here for part two.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Additional Sources:

Waesch, Amanda; Cohen, Frank and Weiss, Sean. “The Truth about ZPICs – Why Oversight is Needed.” Brennan Manna & Diamond Law firm. (August 29, 2017). Web.

Carlson, Joe. “Review notes ZPIC oversight woes.” Modern Healthcare. (November 14, 2011). Web.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Key Words: Zone Program Integrity Contractors (ZPICs), ZPIC audit defense attorney, ZPIC defense lawyer, Medicare audit defense legal counsel, Medicare audit attorney, legal representation for ZPIC letters, legal representation for ZPIC audits, Medicare and Medicaid audits, legal representation for Medicare and Medicaid audits, health care fraud defense attorney, preparing for ZPIC audit, legal representation for health care fraud, Centers for Medicare and Medicaid (CMS), legal representation for CMS investigations, Office of Inspector General (OIG), health care professional defense attorney, legal representation for health care professionals, legal representation for fraud investigations, reviews for The Health Law Firm, The Health Law Firm attorney reviews, additional documentation requests (ADRs) for pre-payment and post-payment reviews, initiation of Medicare suspension of payments lawyer

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2017 The Health Law Firm. All rights reserved.

 

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What You Need to Know About Preparing and Responding to an Initial Medicaid Audit Request

1 Indest-2008-1By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Health care providers in Florida who service Medicaid patients are at a higher risk for audits than anywhere else in the country. The unfortunate truth is that Florida has become synonymous with health care fraud. As a result, auditing and subsequent overpayment demands are very real possibilities.

The Health Law Firm and its legal professionals represent health care providers in virtually every aspect of Medicaid program audits, investigations and litigation. These include physicians, medical groups, mental health professionals, pharmacies, nursing homes, home health agencies, hospitals and other health facilities.

Facts You Should Know About the Medicaid Audit Process.

Should you find yourself, your facility or your health practice the subject of a Medicaid audit by your state Medicaid agency or audit contractor, there are a few things you should know. The most important thing to remember is that just because you are being audited, it does not mean that you or your business have done anything wrong. State and federal governments conduct audits for several different reasons. Typical ones include: special audits of high-fraud geographic areas, auditing of particular billing codes, randomly selected provider auditing and complaints of possible fraud.

If You Are the Subject of an Audit.

A Medicaid audit will usually begin with the provider receiving an initial audit request, usually by letter or fax. This request will serve to notify the recipient that it is the subject of an audit. The initial letter will not always identify the reason for the audit. It will, however, contain a list of names and dates of service for which the auditors want to see copies of medical records and other documentation.

Once the records are compiled and sent to the auditor, the process shifts and you are now going to have to dispute the auditor’s findings in order to avoid overpayment.

The biggest mistake that someone who is the subject of an audit can make is to hastily copy only a portion of the available records and send them off for review. The temptation is to think that because the records make sense to you, they will make sense to the auditor. Remember, the auditor has never worked in your office and has no idea how the records are compiled and organized. This is why it is so important to compile a thorough set of records. The records should be presented in a clearly labeled and organized fashion that provide justification for every service or item billed.

Compiling a Response to an Initial Audit Request.

The following are steps that you should take in order to compile and provide a set of records that will best serve to help you avoid any liability at the conclusion of the audit process:

1. Read the audit letter carefully and provide everything that it asks for. It’s always better to send too much documentation than too little.

2. If at all possible, compile the records yourself. If you can’t do this, have a compliance officer, experienced consultant, or experienced health attorney compile the records and handle any follow-up requests.

3. Pay attention to the deadlines. If a deadline is approaching and the records are not going to be ready, contact the auditor and request an extension before it is due. Do this by telephone and follow up with a letter (not an email). Send the letter before the deadline.

4. Send a cover letter with the requested documents and records explaining what is included and how it is organized as well as who to contact if the auditors have any questions.

5. Number every page of the records sent from the first page to the last page of documents.

6. Make a copy of everything you send exactly as it is sent. This way there are no valid questions later on as to whether a particular document was forwarded to the auditors.

7. Send the response package using some form of package tracking or delivery confirmation to arrive before the deadline.

Compiling all of the necessary documentation in a useful manner can be an arduous task. If you find that you cannot do it on your own, or that there are serious deficiencies in record keeping, it is recommended that you reach out to an attorney with experience in Medicaid auditing to assist you in the process.

To learn how The Health Law Firm can assist you with a Medicaid audit, click here.

If you have been accused of Medicaid fraud and need to prepare for an audit, click here to watch our informational video blog.

Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at http://www.TheHealthLawFirm.com.

About the Author: George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.
KeyWords: Medicaid fraud defense attorney, Medicaid audit defense attorney, legal representation for false billing, legal representation for Medicaid overpayment, legal representation for Medicaid audit, legal representation for Medicaid investigation, health care fraud defense attorney, Medicaid fraud attorney, Centers for Medicare & Medicaid Services (CMS) , legal representation for allegations of overbilling, audit defense attorney, ZPIC audit defense attorney, legal counsel for responding to Medicaid audits, legal representation for Medicaid fraud allegations, legal counsel for Medicaid audits, reviews of The Health Law Firm, The Health Law Firm attorney reviews

“The Health Law Firm” is a registered fictitious business name of and a registered service mark of The Health Law Firm, P.A., a Florida professional service corporation, since 1999.
Copyright © 2017 The Health Law Firm. All rights reserved.