What is a ZPIC Audit and How Could They Affect Your Practice?

A ZPIC (Zone Program Integrity Contractors) audit comes with little warning. ZPIC was founded in the US by CMS (Centers for Medicare & Medicaid Services) with the mandate to look into issues like fraud, abuse, and waste among Medicare providers.

For this reason, it can be quite distressing to learn that you are a candidate for a ZPIC audit. This is because the only time these guys come knocking is when they have a reason to think you have used Medicare funds inappropriately.

How ZPIC Audits are Different from Other CMS Audits

ZPIC audits are not random like other CMS fraud detection and prevention programs. ZPIC audits are focused, which means that when these auditors come to your institution, they have a reason to believe that you are wasteful, abusive, or fraudulent in your use of the Medicare monies.

Reasons for ZPIC Audits

Still, you might see the ZPIC audit coming – they are based on certain red flags. For instance, employees or beneficiaries might complain about your services directly to the authority, prompting an audit. It could also be that other government agencies have found certain discrepancies between your institution’s claims and the regional norms. ZPIC itself has also been know to conduct data analysis, and these can reveal unusual patterns in billings, provision of certain services, and so forth; which can prompt an audit.

What’s a ZPIC Audit Like?

In the course of the audit, ZPIC officials can make unannounced visits to your premises and demand several records regarding your patients and your business. They can also conduct interviews with staff members.

Often times, when these auditors pay you a visit, the investigation is usually well underway. That’s right – they may not inform you that they are going to audit you. But that is not to say there is little you can do to mitigate the potential damage the results of these audits can do to your institution.

What to Do when Faced with a ZPIC Audit

If a ZPIC audit is launched against your institution, you will need to prepare yourself adequately by getting topnotch legal representation. That is because the consequences of this audit can be quite dire. For instance, the investigators can recommend that you be excluded from the Medicare program, or pass any payment claims through them for approval.

How A Good ZPIC Can Help You

With an experienced ZPIC audit team on your side, you can sidestep some of the potential pitfalls that might come from this investigation. For instance, you have the right to dispute or question any unreasonable request for information. And the best way to know that you are getting an unreasonable document request is to have an experienced legal team reviewing such requests before you act on them.

In some cases, you might need more time to provide the required information, and getting approval for a time extension is usually a coin flip. Again, a good legal team can help you deal with such challenges during the audit so that you don’t end up in more trouble than necessary.

Also, these audits go a lot better if you are able to comply to the auditors’ requests in a timely manner. Having legal specialists to help you out makes this easier. Your conduct during the audit can also influence some the drastic decisions that ZPIC takes after the audit is concluded, it could even cost your membership to the Medicare program. So, to ensure that you understand all requests properly and respond to them in proper time, getting a good legal team is a good idea.

Why You Need A Legal Team Even After The Audit

You should not just have a legal team helping you out during your audit, but also after the audit is concluded. In fact, this might be the best time to work with your legal team to ensure that any temporary restrictions placed on your institution can be resolved. In these circumstances, the auditors usually realize that the red flags your institution raised were caused by billing errors and other minor issues that can be easily rectified.

And why is it so important to take these requests seriously? Usually, failure to meet these minor recommendations in time might cause greater woes for you, including court cases and removal from the Medicare program. However, with a good legal team on top of things as you try to right any issues the audit might have uncovered, you can rest assured that it will be a lot easier to satisfy ZPIC demands and restore your full status as a Medicare provider.

Additionally, if it turns out that the auditors have decided to open a court case against you, a good team of lawyers will be needed to help you argue your case in court and help you avoid severe legal liabilities. Besides, there are cases where the ZPIC auditors may decide to impose some crippling restrictions on your institution.

In such a scenario, appealing the decision might be worth a shot. But to do so, a good legal team is necessary so that you don’t end up with even greater problems than when you first started. In short, lawyers with ZPIC experience can help you know beforehand if appealing the audit results is better than accepting them.

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