Have You Been Notified Your Medical Practice Is Under a ZPIC Audit?

 Posted on March 29, 2022 in Professional License Defense

In the past 20 years or so, there has been a concerted effort by the federal government to crack down on the number of fraudulent claims that are submitted to Medicare by medical providers. One of the ways that the government prevents fraudulent claims is through prepayment audits. If your practice has been notified that you are the subject of a prepayment audit, you should contact an Illinois professional license defense attorney for legal assistance.

Zone Program Integrity Contactors

Prepaid audits fall under the bailiwick of the Centers for Medicare and Medicaid Services. The agency often employs Zone Program Integrity Contactors (ZPICS) to conduct these investigations into potential waste, abuse, and fraud. In some cases, ZPICS will use methods to mine the practices’ algorithms in an attempt to see if they can find any abnormalities in billing which could indicate fraud is taking place.

Issues That Can Result in a Prepayment Audit

There are certain issues that can result in ZPICS knocking at your door or a denial of claims:

• Failure to provide proof that certain treatments, services, medications, or equipment are medically necessary

• Complaints filed by patients or employees - In some cases, there may be a whistleblower to reports the alleged fraud.

• Missing documentation, missing signatures, etc

During the audit, ZPIC will usually visit the practice in person, interview employees, and request copies of medical records and other documentation. They will be looking for any evidence of the following:

• Intentional duplicate billing

• Intentional billing for services not provided

• Changing medical records or claims to get a higher payment

• Billing services that are classified as non-chargeable or non-covered as covered

Audit Results

If a ZPIC rep finds any evidence of fraud or waste, they can suspend Medicare payments, as well as require that the provider reimburse the government for any overpayments.

In addition to the significant financial impact an audit can have on a practice, the results can also be forwarded to the Illinois Medical Licensing Board, resulting in the suspension of the provider’s license, as well as both civil and criminal charges.

Contact an Illinois Medicare Fraud Attorney

If you are a provider in Illinois and you have been notified that you are under a ZPIC audit, contact The Law Offices of Joseph J. Bogdan, Inc. immediately for legal representation. Failure to have a dedicated Illinois ZPIC audit attorney representing you through this process can result in devastating personal, professional, and financial losses, as well as potential criminal convictions. Call 630-310-1267 today to schedule a free and confidential consultation.

Sources:

https://www.cgsmedicare.com/hhh/medreview/zpic.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/RecoveryAuditPrepaymentReview