The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contains information about each zone as well as activity and updates in those regions.
|ZPIC||Zone||States in Zone|
|Safeguard Services (SGS)||1||California, Hawaii, Nevada, American Samoa, Guam, Mariana Islands|
(subcontractor to AdvanceMed)
|2||Alaska, Arizona, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming|
|Cahaba Safeguard Administrators||3||Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin|
|Health Integrity||4||Colorado, New Mexico, Oklahoma, Texas|
|NCI AdvanceMed||5||Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, West Virginia|
(being handled by Safeguard Services until resolution)
|6||Connecticut, D.C., Delaware, Maine, New Jersey, New York, Maryland, Massachusetts, New Hampshire, Pennsylvania, Rhode Island, Vermont|
|Safeguard Services (SGS)||7||Florida, Puerto Rico, Virgin Islands|
Zone Program Integrity Contractors (ZPIC) was established under the Medicare Modernization Act of 2003 and details of this Act required CMS to implement competitive measures for program integrity. ZPICs were established to detect, deter and to prevent fraud, waste and abuse in the Medicare program. With this Act, ZPIC was further defined and assigned to seven program integrity zones and assigned to cover specific Medicare Administrative Contractor jurisdictions which are hired by CMS/Medicare to perform medical review, data analysis and extensive Medicare audits.
ZPIC audits are among the most dangerous audits for practices today. In most cases, ZPIC audits are prompted by the results of data mining, complaints by employees, complaints by beneficiaries, request by Medicare contractor and other methods. In short, while it isn't always the case, in many cases where a ZPIC audit is in motion, it is because erroneous billing practices are highly suspected and "ammunition" has already been collected by the ZPIC auditor, triggering this degree of investigation.
Note too, that ZPIC are paid on a performance basis, which means that the greater success they have in recoupment, the more they will benefit financially. Of course, for any other organization or individual whose earnings are determined by performance, the motivation to produce is generally quite high.
ZPIC has the ability to impose severe sanctions in addition to the overpayment determined and has great authority with few limitations.
Some of the things that ZPIC is able to do includes:
- Conduct a sample audit of previously paid claims
- Conduct large post payment audits
- Conduct an unannounced visit and audit of your practice
- It should be noted that these unannounced visits appear to be increasing in ZPIC zones
- Interview beneficiaries regarding care they have received as a method to determine if care was medically necessary
- Place your practice on prepayment review
- Which also means that you will receive no payments until this review is conducted and whatever findings there are have been resolved
- Recommend to CMS that your Medicare payments be suspended
- Which can last for several months to a number of years
- Recommend to CMS that your Medicare number be revoked
- Make a referral to the Health and Human Services, Office of Inspector General for investigation of civil or criminal liability
- Make a referral to the U.S. Attorney's Office for investigation of civil False Claims Act violations or for criminal prosecution.
In the event of a ZPIC audit, compliance and timeliness to requests is necessary and a qualified healthcare attorney can be quite helpful with the processes that occur with this type of audit.
Certainly, there are things that every practice can and should do in effort to prevent audits and record reviews and to minimize the penalties in the event an audit should occur. There are many preventative and protective steps that practices should take, including ensuring Medical Necessity, properly coding and submitting claims, using appropriate fees, fulfilling documentation requirements and knowing the qualifications to determine coverage for services being rendered.
With questions or for additional assistance, please contact ChiroCode.