Zone Program Integrity Contractors (ZPIC) Audits

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Zone Program Integrity Contractors (ZPIC) Audits

ZPIC stands for Zone Program Integrity Contractors. Created by the Centers for Medicare and Medicaid Services (CMS), ZPIC audits are used to identify and remedy fraud in Medicare and Medicaid. The CMS has created seven (7) zones to monitor the entire country, with each zone comprising anywhere from two (2) to twelve (12) states. They audit United States territories, as well, such as Puerto Rico, Guam, the Virgin Islands, American Samoa and the Mariana Islands. The zones are aligned with each state or territory’s Medicare Administrative Contractors (MAC) zone.

Who Is at Risk for ZPIC Audit?

While some think ZPIC audit selection is arbitrary, it’s usually based on two things: consumer complaints or data analysis. Consumer complaints usually come from employees or their beneficiaries. Data Analysis, however, will uncover:

  • patients with extended home health care visits,
  • patients with long stays in hospice care, or
  • acute care facilities with either a large number of cases or an unusual mix of cases.

How to Prepare for a ZPIC Audit

First of all, learning that your organization is being subjected to a ZPIC Audit isn’t an accusation; it’s merely an investigation to ensure fraud hasn’t occurred. But it’s important to implement the following to reduce any potential red-flag occurrences. And if a ZPIC Audit should occur, implementing the following will help you answer questions, provide appropriate documentation, and maintain accountability

Implement an Effective Plan
Make sure you fully understand each of the regulatory and statutory provisions related to the services you bill to Medicare. Then ensure all of your coding, documentation and billing practices adhere to these rules. If you discover any inconsistencies, remedy them immediately, and make sure the plan addresses how these will be prevented in the future.

Never Ignore any Requests for ZPIC Documents
Reply promptly to any documentation requests by your ZPIC. Not doing so could result in your organization’s suspension from participation in the Medicare program.

Educate Your Staff
Make sure your staff fully understands all requirements as they relate to Medicare coding and billing. As well, make sure you outline and educate each staff member on your records management procedures.

If you’re wondering whether your organization is at risk of a ZPIC Audit, these tips will help you get headed in the right direction. It’s important to remember, however, that navigating the broad Medicare regulatory landscape can be a very daunting and expensive task. It’s always best to consult with an experienced healthcare law attorney. They’ll help you and your organization navigate the way through the ZPIC Audit process.


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