What is a ZPIC audit?
Zone Program Integrity Contractors (ZPIC) are responsible for investigating suspected fraud, waste, or abuse in the Medicare program and healthcare providers. They are given powers to conduct detailed audits on a massive scale on behalf of the Centers for Medicare and Medicaid Services (CMS).
What does Zpic stand for?
Zone Program Integrity Contractors (ZPICs) are federal contractors that work under the direction of the Centers for Medicare and Medicaid Services (CMS) to uncover fraudulent billings under Medicare.
How can a ZPIC audit be initiated?
ZPICs do not conduct random audits. They initiate focused reviews when fraud is suspected….ZPICs may initiate the following:
- Requests of medical records.
- Interviews with patients and provider employees.
- Unannounced site visits.
- Analysis of data and error rate.
What are ZPICs looking for?
ZPICs are private companies contracted with CMS for the sole purpose of investigating potential issues of fraud and abuse within the Medicare Program. Through the use of audits, ZPICs look to develop allegations of fraud into referrals for possible criminal or civil prosecution by multiple law enforcement agencies.
Who are the UPIC contractors?
The contracting process culminated in the award of UPIC contracts to the following private sector contractors on in May 2016:
- Health Integrity, LLC (Western Jurisdiction)
- AdvanceMed Corporation (Midwestern Jurisdiction)
- IntegriGuard, LLC, dba HMS Federal (Indefinite Delivery Indefinite Quantity)
Which ABN modifier indicates that a signed ABN is on file?
Modifier GA
Modifier GA — must be used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary, and they do have an ABN signed by the beneficiary on file.
What is not a responsibility of a Zone Program Integrity Contractor?
ZPICs do not handle complaints, audit cost reports, or process claims. All medical and documentation review is specifically for the purpose of verifying benefit integrity.
What triggers a Upic audit?
Typically, UPIC audit selection is based on consumer complaints or data analysis. A consumer complaint comes from the company’s employees or the beneficiaries. Meanwhile, data analysis will search for a large number or mix of cases.
How do I get an Upic number?
What documents do I need to obtain a UPIC? You need to submit the ownership proof of your property at the time of data collection. It could be either a registered sale deed, conveyance deed, electricity Bill, fixed-line telephone bill, or Municipal Tax receipt.
How far back can Medicare RAC audits go?
Medicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed.
How are providers identified for zpic audits?
Most providers and suppliers are identified for audit and / or investigation through an analysis of their billing practices. It has been our experience that approximately 80% to 90% of the providers we have represented in ZPIC audits were first targeted through data mining.
Is the Zone Program Integrity contractor ( zpic ) still working?
Today, a few legacy ZPICs are still working on CMS projects but for the most part, all of their program integrity duties have been transferred over to UPICs around the country. For a detailed discussion of the current UPIC program, we recommend you review our page titled “A UPIC Audit is Serious Business — Is Your Office Prepared?”
What is the most stressful part of a zpic audit?
One of the most stressful parts of a ZPIC audit comes when the auditors uncover ways in which your Medicare claims don’t meet coverage requirements. While you can file a redetermination appeal, it’s easier to avoid overpayment assessments altogether.
Why is it important to have zpic compliance plan?
This is just one of the reasons it’s important to have a plan in place, to protect your business and its employees. A ZPIC compliance plan is a strategy you can implement to stay on the right side of Medicare billing regulations, so that you can rest assured that no one in your practice is committing Medicare fraud, inadvertently or otherwise.