Four Improper Payment Protocols that Can Trigger ZPIC Audits

ZPIC audits

Medicare fraud is a complex and often confusing issue, both for health care facilities and for the government. Fraud cases aren’t always straightforward or easy to spot, and what’s more, they aren’t always intentional. When ZPICs audit and discover these cases, they often define them not as outright fraud but as abuse. Exactly where an audit falls on the spectrum of an innocent mistake to outright fraud can vary; most cases fall within one of the following four categories.

Outright Mistakes

Everyone makes mistakes. And when large amounts of billing and payments are involved, the risk of error increases. Numbers can be difficult to work with at the best of times, especially when computers are involved. It is possible for a billing specialist to cause an audit due to errors within the billing system itself. This includes entering the incorrect code, entering too many codes (e.g. duplicating a service accidentally), or failing to include any required details about the service provided.

Often, mistakes that occur at this level really are true mistakes. In fact, true mistakes happen more often than they should. They aren’t intentional, nor are they a result of the provider trying to fraudulently access Medicare. However, they are still considered illegal and actionable under Medicare guidelines. In any event, an audit due to a simple error can become much more serious than you might expect.

Inefficiencies and Waste

Providers are expected to optimize their services to best fit Medicare guidelines. Excessive waste or inefficiency is defined as anything unnecessary, or which could be provided under a more cost-effective claim. For example, ordering excessive diagnostic tests after previous diagnostics have already ruled out a diagnosis could be seen as a Medicare violation. Likewise, repeating services or offering services when they aren’t expressly required may fall under the same category. Unfortunately, inefficiencies and waste can happen because of simple errors as well.

Intentionally Bending the Rules

Providers who upcode or stack billing for a better payout may be at fault for Medicare abuse or fraud, too. This includes coding a claim for a slightly more expensive service even if you actually provided the lesser service instead. Every code must paint an accurate picture of the service provided.

Outright Deception

Outright deception is defined as anything the provider does for the express purpose of defrauding and abusing the Medicare system. This includes billing for services never rendered, piggybacking codes onto another claim, and any other situation where you request money from Medicare when it isn’t deserved. Intentional fraud audits are extremely serious, and if you find your facility or provider accused, it’s crucial that you contact an experienced lawyer for assistance immediately.

Contact Experienced ZPIC Audit Attorneys

Regardless of what causes the ZPIC audit, the process can be complicated and overwhelming. You have a lot on the line. Make sure you have a qualified ZPIC attorney on your side who can help you defend yourself against a ZPIC audit. Contact the attorneys at Oberheiden & McMurrey, LLP at (888) 727-5159 or complete our online contact form today.

This information has been prepared for informational purposes only and does not constitute legal advice. This information may constitute attorney advertising in some jurisdictions. Reading of this information does not create an attorney-client relationship. Prior results cannot guarantee a similar future outcome in your case. Oberheiden & McMurrey, LLP is a Texas LLP with headquarters in Dallas. Mr. Oberheiden limits his practice to federal law.