![]() ![]() When reviewing billing data, ZPICs look for outliers such as a high volume of billings for a particular service or lengths of stay outside of industry standards-which suggest that a provider might be overbilling Medicare. ![]() ![]() Data Analytics – ZPICs rely heavily on data analytics to identify healthcare providers to audit.The four primary triggers for ZPIC audits are: an internal Medicare compliance audit) may be necessary. When facing a ZPIC audit, understanding what triggered the audit can be important for developing an informed defense strategy and determining what other measures (i.e. ZPICs choose healthcare providers to audit through four primary means. How ZPICs Choose Healthcare Providers to Audit However, some ZPICs are still operating at this time and, for the foreseeable future, it is likely that the acronyms ZPIC and UPIC will be used interchangeably in the healthcare sector. Recently, CMS overhauled its audit contractor program and replaced ZPICs with Unified Program Integrity Contractors (UPICs). Nick Oberheiden, Founding Attorney of Oberheiden P.C. ZPIC audit determinations are often misguided, and this makes it particularly important for providers to engage and defend themselves during the audit process.“ – Dr. “ZPIC audits present significant risks for healthcare providers. However, as “fee for service” contractors working with CMS, ZPICs are only financially incentivized to identify overpayments and seek recoupments, and this means that ZPIC audits usually only focus on determining whether these contractors can lodge accusations of fraud. Their “integrity” function is intended to ensure that both CMS and the providers that bill Medicare achieve fair outcomes. Technically, ZPICs are tasked with identifying both overpayments and underpayments. Department of Justice for further enforcement action. ZPICs have broad authority to conduct audits of Medicare-participating healthcare providers and, following audits, ZPICs can directly impose sanctions and/or refer providers to CMS or the U.S. 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. ![]()
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