Category: ZPIC Audits

A ZPIC audit is a very serious matter that could have serious consequences for the entire facility and some of the professionals who work in the facility. For that reason, it is a good idea to make sure everything is in order and prepared for a ZPIC audit, especially if you know one is coming. Make sure everyone in your organization is as ready as possible, including your staff.

Contact Professionals

Although you don’t always have time to prepare, it doesn’t hurt to make plans just in case. Even if you know that you face an audit in the future, the first thing you should do is to contact your legal representative as well as the individual or group responsible for all the medical records.

You’ll need to be able to plan for staffing so that anyone who needs to help with the audit can give it their full attention. You may need to schedule extra staff members to be at the facility so that the business of the day can go on without delays while making sure there are also enough people available to work with the audit undisturbed.

Even if you aren’t facing an audit, you can involve your legal representative. Your attorney can advise you, ensure you retain your rights from the beginning, and help you determine the best way to proceed. Your attorney can also be present for the audit and request documentation to review the validity of it.

Remain Calm

Although a ZPIC audit should be taken seriously, it is not the end of the world. In some cases, it’s really just a random pick or a minor error, so your facility may not have even sent up red flags. It’s important to help your team and staff members remain calm. Although it’s business as usual, there is some risk, so it’s a good idea to ask your staff to review all elements of the necessary files to make sure everything is in order.

Essentially, you need to make sure you have enough staff to handle the audit as well as the daily functions. However, the most important thing to do is make sure you have a qualified legal team on your side, whether you’re just preparing for an audit, facing an audit, or planning to appeal. Your attorney can often share information regarding specific things your facility needs to do to prepare for an audit or reasons your facility might be targeted.

Contact a ZPIC Audit Lawyer Today

It’s important for your business that you make sure everyone is prepared in the event of a ZPIC audit. This could mean extra training or self-assessment, or it could mean helping your staff remain calm throughout the audit.

In any event, you have a much better chance of successfully managing an audit, if you have an experienced attorney in your corner. Contact Oberheiden, P.C. at (888) 727-5159 or fill out our online contact form for a free and confidential consultation.

Medicare fraud is a serious issue in the United States. Zone Program Integrity Contractors (ZPICs) monitor and take action against Medicare fraud when they suspect it has occurred. This process begins with a ZPIC audit, which is considered a general investigation into whether or not a health care facility or office has committed any fraud. However, understanding exactly what constitutes ZPIC fraud and how you can prevent it from occurring isn’t always as straightforward.

How Does the Government Define Fraud?

According to Chapter 2, Sec. 2.4.C of the Medicare Program Integrity Manual (MPIM), Medicare fraud includes claims identified as, (fraudulent, wasteful, or abusive,) in nature. What this means is that if a ZPIC can identify that a claim for Medicare wasn’t required, wasn’t legal, or could have been handled with a lesser claim, it may constitute fraud against the Medicare system. Providers are expected to self-manage their claims for efficiency, though help and guidance are available through overseeing bodies when required.

Understand that ZPICs only begin investigations after identifying a potential fraud case, not the other way around. This leaves facilities in the position of proving their innocence.

Examples of ZPIC Fraud

You might think fraud, in general, is fairly easy to define. However, when it comes to ZPIC audits and fraud, it can be a bit more complicated. Fraud in the Medicare system is extensive, and the ways in which it occurs can be complex and often subtle. Most ZPICs agree that the following examples constitute clear signs of fraud on the part of the medical facility:

• Filing a claim when no service is provided
• Padding claims with false information
• Filing a claim for a provider who isn’t licensed to practice medicine
• Offering, accepting, or otherwise being involved in kickbacks

Other examples might include filing a claim for an unapproved beneficiary, claims for off-label prescription drug use, stark Law violations such as self-referral to a partner, and claims with inadequate supporting documentation.

This list is far from exhaustive. Other less obvious forms of fraud may include prescription fraud (such as when a physician prescribes medication for a family member), doctor shopping (when a patient sees multiple doctors in a short period of time), false price reports (including samples and free products in total claims), and other serious offenses. As you can probably guess, it can be difficult to assess whether or not fraud actually took place.

Every medical entity should understand and follow Medicare guidelines at all times. If you discover you are being audited, do not attempt to work the issue out with your ZPIC. Contact a Medicare fraud lawyer immediately for guidance.

Experienced ZPIC Audit Attorneys at Oberheiden, P.C.

A ZPIC audit is a serious matter that can cost you your business. Make sure you have a qualified ZPIC attorney on your side who can help you defend yourself against a ZPIC audit. If you are being audited or need help with an appeal, contact the attorneys at Oberheiden, P.C. at (888) 727-5159 or complete our online contact form today.

If you’ve received notification that your medical practice is the subject of a ZPIC audit, the first thing to remember is not to panic. This doesn’t have to be a negative experience, as long as you have an experienced team on your side to help you throughout the process. In addition, arming yourself with some knowledge and strategies can help you, your business, and your employees come out ahead after an audit. Here are 4 things you should do if you find yourself in the middle of a ZPIC audit.

Maintain Communication

During an audit, you should maintain open communications with the ZPIC in charge. Stay calm, professional, and pleasant during any communications with him or her. Consider communicating only via email or other written correspondence, so there is a record of what was said by both of you. In fact, it is usually best to consult your attorney before you communicate with anyone.

Don’t Ignore Requests

Many times, businesses choose to ignore requests. However, one way to maintain the open communication noted above is to pay attention to and address the requests of the ZPIC. Whether the request is for additional documentation or a deadline for producing the necessary paperwork, it’s important to acknowledge the request and get to work on meeting it.

Retain an Experienced ZPIC Audit Attorney

The receipt of a notification of a ZPIC audit is your prompt to secure the services of an experienced attorney. If you question the necessity of retaining counsel who has specific experience with medical audits, just remember something that you’ve likely told a patient or two. A patient who is having heart palpitations shouldn’t make an appointment to see an ENT. Instead, a cardiologist should be consulted. Likewise, you should also seek out someone who has experience defending organizations against ZPIC audits.

Enact a Compliance Code

Even if you already have language addressing compliance in your employee documentation, being the recipient of a ZPIC audit makes this a good time to update it. All new employees should be required to thoroughly read the compliance information and sign off on it to demonstrate their understanding. The staff that you have working for you currently should be introduced to the updated version. One way to do this quickly and easily is to have a staff meeting in which the compliance points are gone over one at a time. Ensure that everyone signs one before they leave the meeting.

Being the subject of any audit can not only be frightening, but it can also reduce the amount of cash flow to your practice. Retaining a legal team with experience in ZPIC audits helps to address these setbacks.

Experienced ZPIC Audit Attorneys at Oberheiden, P.C.

Don’t make the ZPIC audit more difficult for yourself and your business than it needs to be. Make sure you have the right legal team on your side to help you through it. If you are being audited or need help with an appeal, contact the attorneys at Oberheiden, P.C. at (888) 727-5159 or complete our online contact form today.

A ZPIC audit is conducted to ensure that you and your staff follow proper guidelines and procedures. Although it might sound simple enough, the ZPIC audit process can be complex and overwhelming. This is primarily because the guidelines and procedures that govern Medicare and programs like it are ever-changing and submerged in small details that can mean everything when it comes right down to it. Because of the risks that can come with an audit, it’s crucial that you understand what’s at stake. These are some of the risks that come with a ZPIC audit.

Fines and Fees

When it comes to any type of government inspection, you can be sure that fines and fees will be involved. For the government, it is a measure taken to prevent carelessness with sensitive information and policies. Minor infractions can lead to costly recoveries, but fines and fees (as long as they aren’t so extensive as to break the bank) are often the least of your worries after a ZPIC audit.

Criminal Charges

You could face an even greater risk of criminal charges. Government entities do recognize that mistakes can be made and understand that neither machines nor humans are infallible. At the same time, they also recognize a difference between a mistake and deliberate misuse of information and funds. That difference can carry a label that can result at the end of a career, your freedom, and even of life as you know it. That label is “fraud” and though it doesn’t happen often, it has been applied in times when a legitimate mistake was made.

Protection from the Risks of an Audit

The best thing you can do to protect yourself and your facility are to follow all guidelines precisely and document every facet of the process. This includes everything from identification and insurance cards to staff notes and photographs of the injury or issue at hand. The more documentation you have, the less likely you are to overlook an important point or unknowingly violate a guideline or law. Further, your documentation can be the proof you need if fraud is in question.

The risks associated with a ZPIC audit can be life-altering. To understand your specific risks and how you can remain in compliance, it’s best to have an experienced lawyer who understands the process and all the elements involved.

Avoid the Risks that Come with a ZPIC Audit

In many cases, you can’t avoid getting audited. Unfortunately, even if you think you have followed all the guidelines and have managed your business as you should, you could still be at risk of some of these consequences. A simple error can change your entire business.

If you are faced with a ZPIC audit or you’ve been audited and would like to appeal, we can help. Contact our attorneys at Oberheiden, P.C. for a free and confidential consultation. Call (888) 727-5159 or fill out our online contact form right away.

Businesses that provide services covered by Medicare can occasionally find themselves under investigation by Zone Program Integrity Contractors, also known as ZPICs. ZPIC audits are intended to check for and reduce the occurrence of Medicare fraud.

The Audit

Medicare payments are monitored, and any unusual activity can be cause for an audit. During the investigation, ZPICs work to determine whether there is fraudulent activity, or if there are simply errors made in the billing process.

In cases where fraud is found, the case is sent to the Office of the Inspector General (OIG) and the Department of Justice (DOJ). While recuperation of overpayment is likely for those who simply had errors in their billing practices, fraudulent activity can result in monetary penalties and even criminal charges.

Common Mistakes During a ZPIC Audit

During an audit, ZPICs will require access to most or all business records. While it is good to cooperate with this process, employees sometimes certify that their information and documents are complete without checking, which can be a costly mistake for the facility and the professionals who work there.

Not having a qualified defense attorney with experience in Medicare fraud cases on your side to help you throughout the process can make it even more difficult. The audit process adds additional stress to the normal operation of a business and can be confusing and overwhelming to everyone involved. In the end, it can become the perfect recipe resulting in errors that lead to negative results for the business, its employees, and even its customers even if you didn’t advertently do anything wrong.

The Basics of an Appeal

If your ZPIC audit does end up with negative results, you do have the opportunity to appeal. However, many people are unaware of the appeals process for ZPIC audits, which can be even more complicated than the audit itself. First, there are five levels of appeal. The first two levels allow you to request a redetermination from the auditor, and to seek a second opinion from an independent contractor. After that, the appeal must be presented before a judge, appeals board, and finally a federal district court.

The audit and subsequent appeals progress can be long and drawn-out, and difficult to manage without recourse to a legal professional.

Although intended to protect consumers and businesses alike, ZPIC audits are a significant source of stress on a business and its employees. Good business practices, accurate bookkeeping, and experienced legal counsel are all key to getting through an audit, and any appeals that may result.

Speak with an Experienced Attorney About Your ZPIC Audit

As you can probably guess, the best thing you can do is ensure that you have a qualified legal team on your side. Make sure you don’t make costly mistakes that can affect your business and its employees. To learn more about defending yourself against a ZPIC audit or if you need assistance filing a ZPIC appeal, you can contact the attorneys at Oberheiden, P.C. For a free and confidential consultation, call (888) 727-5159 or complete our online contact form today.