How to Prepare for a ZPIC Audit

The use of zone program integrity contractor (ZPIC) audits as a means to crack down on waste, fraud, and abuse in the Medicare and Medicaid system have steadily increased over the past decade.

These specialized audits put health care providers at risk of expenditures, lost time and productivity, and recoupment, as well as risks of provider exclusion. Most significantly, they can expose providers to potential allegations of fraud, which are referred to the Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) for civil and/or criminal prosecution.

With stakes as high as these, it’s critical for any provider and business operating in the health care space to create proactive safeguards that minimize their risks for audits, investigations, and prosecution – and to prepare for any audit that does come their way. At Hendershot Cowart P.C., our health care attorneys do just that for clients throughout Texas and beyond.

A Brief Background of ZPIC Audits

ZPIC audits originated from the Health Insurance Portability and Accountability Act (HIPAA), which created the Medicare Integrity Program as a means for helping the Centers for Medicare and Medicaid (CMS) better identify waste, abuse, and fraud. As a result, program safety contractors were created by the CMS to more effectively perform and execute various safeguard functions.

With the passing of the Medicare Modernization Act in 2003, CMS was forced to reform its contracting policies, and replaced fiscal intermediaries with a different type of administrative entity – Medicare administrative contractors (MACs).

With the newly created MAC jurisdictions, 7 program integrity zones were established, giving rise to ZPICS that would perform safeguard functions in their respective zones under the oversight of the Center for Program Integrity.

How ZPIC Audits Begin

Providers in program integrity zones can be picked out for auditing based on various factors, including:

  • Referrals;
  • Patient or provider complaints;
  • Data analysis tools that evaluate the likelihood of fraud.

If you are a provider operating a home health and hospice business, for example, red flags like unusually lengthy patient stays would indicate a greater likelihood of fraud and may warrant an audit.

So, You’ve Been Flagged

ZPICs notify providers they flag for further investigation. However, they also have the power to arrive unexpectedly at any time during the course of the audit. They can also conduct interviews, recommend exclusion, and refer allegations of fraud to federal authorities.

Because of these tactics, and the substantial stakes, prevention becomes the best medicine for dealing with, or reducing your risks of having to deal with, a ZPIC audit.

That means working with experienced attorneys to create and implement comprehensive compliance plans, establish proactive and ongoing means of ensuring regulatory compliance, and preparing for any formal audit soon to come.

Preparing Providers for ZPIC Audits

The diligence, aggressiveness, and promptness with which ZPICs go about their audits are intended to quickly identify improper payments, and ensure swift recoupment for any money Medicare is owed. ZPIC audits are often confusing and concerning matters for providers, but they can be effectively navigated with proper preparation and the help of attorneys who possess the experience and insight they demand.

Our goals in preparing clients for ZPIC audits center on both proactive regulatory compliance and immediate action in assessing and preparing responses, facilitating communication, and minimizing exposure to liabilities and prosecution. We encourage any provider facing a ZPIC audit to immediately reach out for assistance from our experienced health care and medical law team for personalized support and counsel.

ZPIC Audit Tips

Though every case and provider is different, there are a few ways providers can prepare for ZPIC audits:

  • Document, Document, Document – Not being able to provide auditors with requested or important documentation can be a major blow to credibility. Maintenance of proper and accurate documentation are among providers’ most fundamental obligations, and as Medicare pays the bills, it’s entitled to documentation related to its payments. Though the complexity of clinical care and fast-paced environments can make perfect documentation a seemingly impossible task, providers should always be looking to improve policies regarding documentation and organization, as well as policies in high-risk areas, such as billing and coding. Proper documentation can also help providers make the auditing process more efficient, reduce costs and concerns related to lost productivity, and minimize the potential for poor outcomes.
  • Current and Customized Compliance Plans – Providers need to ensure they develop and maintain comprehensive compliance plans that are consistently updated and specific to their organization and relevant regulatory compliance issues. That’s not only because they are required to under the Affordable Care Act, but because doing so can foster better safeguards against risks of audits, investigations, and fraud.
  • Self-Assessment & Proactive Compliance – Having a compliance plan on your shelf does not guarantee compliance. Providers need to take actual and proactive steps if they are to control their risk exposure in any meaningful way. Regular self-assessment, mock audits, and policies that review coding, billing, and documentation practices on a consistent basis are signs of a compliant culture and good faith, and can be powerful tools for reducing audit risks when done properly.
  • Understand the Timeline – Providers should familiarize themselves with the standard timeline of audits, from document requests and production to logs with information about internal procedures and work with outside service providers. Providers should also develop policies for periodic mock audits, with a focus on keeping a chronological timeline of the “auditor’s” actions so as to fully demonstrate efforts made by all parties. Organization and an understanding of time-sensitivity can prepare all employees for working efficiently should a real audit occur.

Seek Help with ZPIC Audits from Proven Health Care Lawyers

Our health care and medical law team at Hendershot Cowart P.C. leverages years of experience in helping providers and medical business professionals through a range of compliance matters, from drafting contracts and billing policies to developing compliance plans, preparing for and navigating audits and investigations, and defending clients against fraud accusations.

We use our insight in this complex practice area to benefit our clients and are available to discuss how we may help you with any potential case during an initial consultation. Call (713) 909-7323 or contact us online to speak with a lawyer.


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