ZPIC Audits Reach Louisiana
The first news of ZPIC (Zone Program Integrity Contractor) activity in Louisiana came earlier this week. An in home provider organization received a request for 30 records, to be sent within 24 days. The records requested are for services provided from mid 2008 to March 2010.
Have you had requests from the Zone Program Integrity Contractors (ZPICs) yet? ZPICs hit HCLA’s radar in the spring of 2010 when we read about a Texas agency that had charts reviewed, visits denied, the extrapolation formula applied and a request for $2.9 million to be returned to CMS.
ZPICs are the latest CMS enforcement weapon to detect fraud and abuse, and they target both the medical necessity of a claim and coding errors. From the operations perspective, expect ZPICs to be disruptive, time consuming for providers, and expensive when it comes to the resources necessary to address requests for information. They can also arrive unannounced, demand medical records, and interview providers and beneficiaries. They can conduct both pre and post payment reviews.
You can find more information about the ZPICs at Medicare’s ZPIC website.
About ZPIC Audits
Zone Program Integrity Contractors (ZPICs), which replaced Program Safeguard Contractors (PSCs), are single-function contractors. ZPICs are responsible for (1) data analysis and data mining, (2) conducting medical reviews in support of benefit inquiry, (3) supporting law enforcement and answering complaints, (4) investigating fraud and abuse, (5) recommending recovery of federal funds through administrative action, and (6) referring cases to law enforcement. Because ZPIC audits are commonly related to an investigation of fraud and abuse, it is essential for Medicare providers and suppliers to align themselves with qualified health care attorneys who possess an in-depth knowledge of the Medicare program and a sophisticated understanding of governing federal regulations.
Unlike the RAC and the CERT which limit their review only to claims that have already been paid, the ZPIC will audit active claims in order to identify fraud. When conducting an audit, ZPICs generally perform a database review of a provider/supplier’s Medicare claims. The ZPICs will compare a provider or supplier’s Medicare billings with that of providers and suppliers of the same type within a designated area. If the ZPIC suspects fraud or abuse, it may conduct an on-site inspection, request additional documentation, review patient records, as well as interview beneficiaries and providers.
ZPIC audits may result in pre-payment and post-payment claims review, the initiation of administrative sanctions, such as payment suspension, overpayments, provider exclusion; and may even lead a provider/supplier being referred to law enforcement.
Want to keep learning? Attend the Fall Leadership Summit on September 22, 2010 in Baton Rouge!
