Zone (Program Integrity Contractor) Defense: Successfully Navigating ZPIC Audits

Sarah Mendiola, Esq., Linda Fotheringill, Esq., Fotheringill & Wade, LLC

While the provider community has been focusing on combating denials from the RACs and MACs, audits by the Zone Program Integrity Contractors (ZPICs) have been quietly recovering hundreds of millions of dollars in identified overpayments. If you talk to a provider who has been involved in a ZPIC audit, you will quickly realize that this type of audit can be devastating in its impact.  This paper explains why the ZPIC is not your typical Medicare auditor and what a provider can do to potentially minimize the impact of a ZPIC audit on their organization.

Issue: ZPICs are looking for “fraud & abuse”, and their audits have the potential to significantly impact the revenue of a hospital through statistical sampling, extrapolation and False Claim Act penalties. Yet, from our work with various hospital providers around the country, we have found that many are not familiar with ZPIC audits and how they differ from audits by the RACs and MACs. A ZPIC medical record request is often handled just like any other auditor request for records.

Takeaway: Do not respond to a ZPIC audit request in a business as usual fashion. Involve your Compliance Officer and executive team at the time records are requested.   Strongly consider enlisting the help of legal counsel experienced with ZPIC audits and the Medicare appeal process. A ZPIC audit can potentially open your organization up to civil and criminal penalties if the ZPIC identifies fraudulent activity.

Check out our white paper for a fuller exploration of this topic.