Health care providers are under tremendous scrutiny for allegations of fraud and abuse in today’s regulatory climate. As a result, they face considerable threats to their practice and exposure to recoupment and civil / criminal penalties when audited by the federal government, Office of the Inspector General, Centers for Medicare Services, the Texas Health and Human Services Commission, Texas Department of Insurance, or private contractors. This being the case, it is essential health care providers who service the Medicare population understand the audit process and respond appropriately when being investigated.
At Hendershot Cannon Martin & Hisey, P.C., we have a dedicated health and medical law legal team with proven experience representing physicians and health-care providers in all areas of Medicare and Medicaid fraud defense. To schedule a consultation with one of our experienced attorneys, call (713) 909-7323 or contact us online 24/7.
What are ZPICs?
Zone Program Integrity Contractors, or ZPICs, are companies contracted by the Centers for Medicare and Medicaid Services (CMS) that focus on investigating suspected fraud, waste, and abuse in the Medicare system. While ZPIC audits are similar to those performed by RACs (Recovery Audit Contractors) and MACs, the differentiating factor is the potential implication for Medicare fraud, which can result in administrative penalties and criminal investigations.
ZPICs do not conduct random audits. They initiate focused reviews when fraud is suspected. This may result from a number of red flags, including:
- Direct complaints / complaints to the Office of Inspector General (OIG)
- Referrals from government contractors (RACs or MACs)
- High frequency of certain services based on local and national patterns
- Unusual billing trends or lengths of stay
- Inaccurate or improper billing
- Mismatched claims with physician records
ZPIC audits, which typically come with little notice, commonly begin with a post-payment audit approach based on medical review and data analysis. ZPICs may initiate the following:
- Requests of medical records
- Interviews with patients and provider employees
- Unannounced site visits
- Analysis of data and error rate
Patterns of Improper Billing
Some ZPIC audits may not turn into cases, and will therefore proceed into recovery of overpayments. However, when ZPIC audits reveal patterns of improper billing that suggest more than errors, auditors consult with the OIG in order to determine the need for further investigation of potential fraud.
Upon additional investigation where fraud is determined, a number of corrective actions may result, including:
- Revocation of provider’s assignment privileges
- Suspension of payments
- Overpayment recovery
- Reporting provider to state licensing board
- Referral to OIG and Justice Department for civil monetary penalties and / or criminal charges
Fighting ZPIC Findings: Appeal Process
Providers are under no obligation to accept audit results, and have the right to challenge audit findings through the appeal process. The Medicare appeal process applies to every denied claim, and includes:
- Request for redetermination – Must be filed within 120 days of initial determination and must include evidence.
- Request for reconsideration – Must be filed within 180 days of redetermination notice with Qualified Independent Contractors (QICs), who evaluate claims and data samples. While all documentation should be filed at this stage, providers do not have an opportunity for hearings or oral arguments.
- Administrative Law Judge (ALJ) Hearing – Must be filed within 60 days of reconsideration decision. As one of the most important stages, providers can explain documentation and call witnesses before an ALJ, who issues their ruling based on the hearing and review. An ALJ ruling may take months.
- Medicare Appeals Council Review – Providers may appeal an ALJ decision within 60 days to the Medicare Appeals Council for review, which may decline review if no errors are evident in the ALJ’s ruling or issue a decision within 90 days.
- Judicial Review in Federal District Court – Must be filed within 90 days of the Medicare Appeals Council decision. This appeal is heard in federal court before a judge, and may include witnesses and testimony.
Fighting ZPIC findings, as well as stopping recoupment in the first two stages of appeal, is a challenging endeavor – but it can be handled effectively by attorneys experienced in health care law, audits, and provider defense.
By taking immediate action to consult with proven lawyers like those at Hendershot, Cannon, Martin & Hisey, P.C., you can gain support in preparing for and navigating the ZPIC audit process. Upon thorough review of your case, appropriate defense strategies may consist of procedural attacks, including ZPIC errors in providing required information or acting prior to a contract, and substantive attacks that focus on clinical findings and denials, legal arguments, and challenges of extrapolated statistics, among others.
Place Your Trust in Proven Health Care Law Attorneys
As recognized leaders in health care law, Hendershot, Cannon, Martin & Hisey, P.C. provides trusted advice, counsel, and legal representation to providers in a range of matters involving Medicare and ZPIC audits, recoupment, fraud, and appeals across the state of Texas. Because ZPIC audits create exposure to troubling outcomes, no time should be wasted in consulting with proven professionals.
Call (713) 909-7323 to request an initial consultation.