How to prepare for a ZPIC audit

Today, healthcare providers face more regulations than ever. One particular form of regulation that has become more common in the past decade are Zone Program Integrity Contractor (ZPIC) audits.

These audits were designed to enforce Medicare regulations and deter improper billing practices. They can lead to allegations of fraud which may bring a healthcare organization civil or criminal charges.

How do ZPIC reviews work?

In 1996, the Health Insurance Portability and Accountability Act (HIPAA) created the Medicare Integrity Program (MIP). This program strengthened the Centers for Medicare & Medicaid Services’ ability to combat Medicare fraud, waste and abuse.

Under these laws, a ZPIC may initiate an audit after identifying a potential for fraud. ZPIC audits are extremely thorough. During the review process, the ZPIC may:

  • Request unlimited medical records and documentation
  • Use data analysis
  • Conduct employee and beneficiary reviews
  • Conduct an onsite visit without prior notice
  • Withhold payments
  • Refer cases to law enforcement

How to prepare for a ZPIC audit

It is important that healthcare organizations do not overlook these audits. When you are selected for a ZPIC review, you should prepare for the review process. A bad audit can land you fraud charges, and a clean one can ensure that you never have to go through the process again. To prepare for a ZPIC audit, you should:

  • Gather and analyze your documents and make edits as necessary
  • Conduct internal audits of your Medicare documents
  • Create an advanced plan to decrease the likelihood of future audits

ZPIC reviews can be costly, even if they don’t lead to formal fraud charges. An experienced health care lawyer can help prepare your organization for a successful ZPIC audit.

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