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 Additional Resources

 
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Zone Program Integrity Contractors

The most serious audit or investigation that you can be involved with is with a ZPIC. In 2009, CMS transitioned responsibility for benefit integrity activities to ZPICs from Program Safeguard Contractor (PSC). The primary goal of the ZPIC is to identify cases in the Medicare program of suspected fraud, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped. 

To do this, ZPIC contractors face no specification regarding look back periods and have access to unlimited document requests. ZPICs have the authority to suspend payments, recoup overpayments through extrapolation, refer the provider to the OIG, and determine if the provider violated its participation agreement. Providers can refute ZPICs through the Medicare Administrative Appeals Process, similar to the RAs. 

ZPICs are divided into seven zones, with four awarded contractors, which are co-extensive with MAC jurisdictions. ZPICs are responsible for identifying cases of suspected fraud and making referrals of all such cases to the OIG, regardless of dollar thresholds or subject matter.

Zone ​Contractor ​States Covered
1​ Safeguard Services, LLC ​CA, HI, NV, America Samoa, Guam and the Mariana Islands
​2 ​NCI, Inc (Previously AdvanceMed Corporation) ​WA, OR, ID, UT, AZ, WY, MT, ND, SD, NE, KS, IA, MO and AK
​3 ​Cahaba Safeguard Administrators ​MN, WI, IL, IN, MI, OH and KY
​4 ​Health Integrity, LLC ​CO, NM, TX, and OK
​5 ​NCI, Inc (Previously AdvanceMed Corporation) ​AR, LA, MS, TN, AL, GA, NC, SC, VA, and WV
​6 ​​Cahaba Safeguard Administrators ​PA, NY, DE, MD, DC, NJ, MA, NH, VT, ME, RI, and CT
​7 Safeguard Services, LLC​ ​FL, Puerto Rico, and the Virgin Islands
   
Review Contractor Directory

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ZPIC Responsibilities 

  • Investigate allegations of fraud, including proactive data analysis results and pre- and post-pay medical review for benefit integrity;
  • Explore all available sources of fraud leads in its zone;
  • Refer investigations to OIG for consideration of civil and criminal prosecution and/or application of administrative sanctions
  • Support law enforcement in requests for information including, but not limited to, data and data analysis, cost report data and medical review
  • Recommend administrative actions to CMS, such as suspending Medicare payment, identifying and recouping overpayments, pursuing civil monetary penalties and recommending program exclusions
  • Prevent fraud by identifying program vulnerabilities to CMS
  • Work cooperatively with law enforcement and others to fight fraud and abuse
  • Initiate and maintain networking, education and outreach activities

What ZPIC audits arise from

  • Data Analysis – a ZPIC could use data analysis to detect high frequency of certain services as compared to local and national patterns, trends of billing, or other information that may suggest that the provider is an outlier
  • Complaints – Employee or beneficiary complaints to the OIG hotline, fraud alerts or event directly to the ZPIC;
  • Referrals – MACs or others contractors and law enforcement agencies may alert the ZPIC

Expectations during a ZPIC audit 

  • Review of claims can be pre-pay or post-pay.  Prepayment review occurs when a reviewer makes a claim determination before claim payment has been made and post-payment review occurs when a reviewer makes a claim determination afte​​​r the claim has been paid;
  • Unlike MACs or RAs, ZPICs are not required to notify providers before beginning a review.
  • ZPICs may request additional documentation (i.e., medical records) and the provider will generally have 30 days to respond.
  • ZPICs may perform an on-site audit and interview your employees
  • ZPICs may interview beneficiaries regarding services rendered.
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