REVENEWS ARCHIVE
Zone Program Integrity Contractors (ZPIC) Detecting Medicare Fraud and Abuse
Similar to the Recovery Audit Contractor (RAC) program which seeks mainly to identify improper payments and is not specifically charged with detecting Medicare fraud and abuse, the Zone Program Integrity Contractor (ZPIC) program is now responsible for identifying Medicare fraud and abuse. According to Centers for Medicare & Medicaid Services (CMS), the ZPIC program will focus on quick response to fraud and administrative actions to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped.
ZPICs were developed from the Program Safeguard Contractors (PSC) program that was created in 1999 with the responsibility to detect fraud and abuse in the CMS benefit plans. While the PSCs could only search for fraud in one benefit plan each, the ZPIC contractors will audit all providers and suppliers of Part A, Part B, Part C, the Medicare prescription drug benefit (Part D), durable medical equipment, prosthetics, and orthotics supplier (DMEPOS), home health and hospice, and Medicaid services. CMS anticipates the ability to review all benefit plans at once will give them a broader look at provider activity and allow them to look for fraudulent billing trends and patterns.
Seven ZPIC contractors will each be responsible for a region of the country, scrutinizing claim submissions to CMS in that region for suspicious behavior. These regions are aligned with the Medicare Administrative Contractors (MAC) jurisdictions. CMS expects that by June 2010, all seven ZPICs will be operational. As of 1/2010, CMS has awarded only three of the seven ZPIC contracts.
- Zone 1 - California, Nevada, American Samoa, Guam, Hawaii, and the Mariana Islands.
- Zone 2- Alaska, Washington, Oregon, Montana, Idaho, Wyoming, Utah, Arizona, North Dakota, South Dakota, Nebraska, Kansas, Iowa and Missouri.
- Zone 3- Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky.
- Zone 4- Colorado, New Mexico, Oklahoma, and Texas. Contract awarded to Health Integrity, LLC
- Zone 5- Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia. Contract awarded to AdvanceMed Corporation, currently under dispute.
- Zone 6- - Pennsylvania, New York, Maryland, Washington D.C., Delaware, Maine, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire, and Vermont.
- Zone 7- - Florida, Puerto Rico and Virgin Islands. Contract awarded to SafeGuard Services, LLC
If the ZPIC uncovers a potential fraudulent pattern in the data, it will conduct an investigation that will require providers to submit supporting documentation for their claims. If the documentation does not match the claims, the ZPIC will refer the case to CMS, which can deny payment, suspend payments, recoup payment and possibly even revoke a provider’s ability to bill CMS. The ZPIC will refer all cases of potential fraud to the Office of the Inspector General (OIG) for consideration of possible criminal or civil prosecution.
In general, ZPICs are going after blatant fraud, leaving administrative coding and billing errors for the RACs, although the RACs are expected to report cases of suspected fraud and abuse when identified. ZPICs will also conduct investigations on issues that whistleblowers submit to Medicare and from referrals by CMS’s claims processing contractors. Similar to RAC denials it will be important to review every ZPIC denial, and to appeal vigorously all inappropriately denied claims as the penalty can potentially be more significant than just a loss of revenue.
References:
Medicare Program Integrity Manual
Medicare Program Integrity Summary of Changes
“The Year of the Audit”, Dimick, Chris. Journal of AHIMA 81, No. 3, March 2010, available online at:
“ZPICs: Bite Worse Than RAC Bark”, Fotheringill, Linda. Healthcare Finance News, September 3, 2009, available on-line at: