What Constitutes ZPIC Fraud?

ZPIC audits

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.