CMS Zone Program Integrity Contractors (Medicare ZPIC Auditors) Turn Up The Heat On Physicians, Hospices, Skilled Nursing Facilities, Home Health Agencies, Physical Therapists & HME Suppliers

While the Medicare Recovery Audit Contractor program (RAC Audits) continues to focus the majority of efforts toward hospital adoption of Medicare coverage policies, CMS has launched another major initiative to directly challenge all other providers.  Although the program - Medicare Zone Program Integrity Contractors (ZPIC audits) - was not officially rolled out with an emphasis on physicians, hospices, skilled nursing facilities, HME suppliers and physical therapy billing, that is exactly where it has been focusing efforts.

Across the southeast, south central, midwest, northeast and west coast regions of the U.S. - ZPIC auditors are in full force.  SafeGuard Services, AdvanceMed, Health Integrity and Integriguard are all pursuing providers with surprise on-site visits, targeted data analysis, random audits, 100% pre-payment holds, extrapolations and follow-up to whistleblower actions.

So, who are ZPIC auditors anyway?  Zone Program Integrity Contractors are organizations hired indirectly (or in connection with other CMS affiliated contractors) by CMS to perform a wide range of medical review, data analysis and Medicare audits.  While ZPIC audits are similar in many ways to other Medicare audits currently being performed nationwide they do differ in one very important aspect – potential Medicare fraud implications.  Of all the current CMS audit initiatives – RAC audits, MIC audits, etc. – it is vital that providers facing ZPIC audits immediately and effectively address targeted audit issues.

How Can Jackson Davis Help?

As your unwavering advocate, Jackson Davis HealthCare (JDH) leads the nation in completing proactice Medicare program integrity audits and developing winning Medicare appeals.  For over 25 years, Jackson Davis HealthCare professionals have dedicated everyday to understanding, documenting, synthesizing and applying Medicare Coverage Criteria for cases being considered for Medicare audits and Medicare appeals - RAC appeals, ZPIC appeals, DOJ appeals, MAC appeals, MIC appeals or individual Medicare beneficiary appeals.

Medicare Appeals - Over the past 25 years, Jackson Davis professionals have worked with providers and attorneys nationwide to appeal 1,000s of Medicare overpayment issues.  JDH partners with leading national and international law firms to maintain attorney-client privilege, establish codified work-product relationships and develop winning Medicare appeals.  We have established working relationships with the nation's best attorneys and they work hand-in-hand with JDH staff to bring you the best, most experienced and most cost-effective solution for your Medicare appeal needs.

Medicare Program Integrity Audits ("Mock" PI Audits) - Jackson Davis HealthCare works closely with providers to complete proactive, detailed & comprehensive Medicare Program Integrity audits (or "Mock PI Audits").  Each Medicare PI audit is centered on documented, codified CMS payment criteria and Medicare coverage criteria for selected focus areas and traditionally includes a pre-determined sampling of 10 - 500 patient encounters.  Each encounter is pre-screened and carefully selected based upon Medicare current or anticipated audit focus areas.  Let JDH physicians, nurses and Medicare compliance professionals go to work for you!

CMS Compliance Advisory Services - Providers nationwide retain JDH for retained monthly counsel or on a project-by-project basis.  Our staff is highly experienced and our knowledge and application of Medicare rules and regulations is unmatched in the industry.  We are Medicare geeks.  From our physicians to our nurses to our compliance reseach team, we are in your corner and available 24/7 for your CMS compliance needs.

ZPIC Audits - CMS Medical Review Process

Prior to the 1996 enactment of the Health Insurance Portability and Accountability Act (HIPAA), Medicare program safeguard activities were funded from the contracted fiscal intermediary’s general program management budget.  However, HIPAA revised the Social Security Act and established the Medicare Integrity Program - accelerating today’s focus on Medicare audits, Medicare fraud, abuse and enforcement of CMS evidence-based coverage policies.

The Medicare Integrity Program’s (MIP) primary purpose is to deter fraud and abuse in the Medicare program by giving CMS authority to enter into contracts with outside entities and insure the “integrity” of the Medicare program.  In 1999, the Centers for Medicare & Medicaid Services (CMS) developed the PSC program to support the MIP, stop Medicare fraud and facilitate provider adherence to codified CMS Payment Criteria, Conditions of Participation and applicable judicial rulings.

ZPIC auditors (formerly known as Program Safeguard Contractors) have a contracted Statement of Work (SOW) that encompasses all of the fundamental activities required for CMS program safeguard activities.  Basically, a ZPIC auditor is generally responsible for one or more of the following Medicare audit focus areas - (1) pre or post pay medical review of claims, (2) data analysis, (3) benefit integrity and/or fraud detection, (4) cost report audits and (5) provider education.

At the highest level, CMS considers an individual ZPIC as being responsible for detecting, deterring and even preventing Medicare fraud and abuse.  In this capacity, the ZPIC auditor is directly responsible for operating areas such as investigation, case development, administrative solutions and referral to law enforcement. 

With the establishment of ZPIC audits, fiscal intermediaries and Medicare administrative contractors typically have some or all of their program safeguard duties removed from the scope of their responsibility.  Step-by-step, CMS appears to be developing a more concentrated functional contracting focus for specific areas such are benefit integrity and claims processing activities.

The CMS Medical Review (MR) program is designed to promote a structured approach in the interpretation and implementation of Medicare policy. The ultimate goal of the MR program is to identify and reduce Medicare program vulnerabilities (areas of potential Medicare fraud or abuse) relating to coverage and by taking the necessary action to prevent or address these areas.

The CMS’ national objectives and goals as they relate to medical review are as follows: 1) Increase the effectiveness of medical review payment safeguard activities; 2) Exercise accurate and defensible decision making on medical review of claims; and 3) Collaborate with other internal components and external entities to ensure correct claims payment, and to address situations of Medicare fraud, waste, and abuse.

In order to identify and challenge perceived Medicare fraud & abuse issues, ZPIC audits are based upon a combination of claims data from multiple sources (fiscal intermediary, regional home health intermediary, carrier, and durable medical equipment regional carrier data).  By combining data that originates from a full range of CMS contractors, the Medicare ZPIC contractor creates a complete profile of the beneficiary’s claim history regardless of where the claim was processed.

Although Quality Improvement Organizations (QIOs) continue to perform reviews related to quality of care and expedited determinations, they no longer perform the majority of utilization reviews for acute PPS hospitals or LTCH claims. The review of acute PPS hospitals and LTCH claims is now the responsibility of other CMS program contractors including: Carriers, Fiscal Intermediaries (FIs), Program Safeguard Contractors (PSCs), Zone Program Integrity Contractors (ZPICs) and Medicare Administrative Contractors (MACs).

While not all contractors perform all Medical Review functions, MR functions may include: analyze data, write local coverage determinations (LCD), review claims and educate providers.  The CMS Medical Review (MR) program is designed to promote a structured approach in the interpretation and implementation of Medicare policy. The ultimate goal of the MR program is to identify and reduce Medicare program vulnerabilities (areas of potential Medicare fraud or abuse) relating to coverage and by taking the necessary action to prevent or address these areas: