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How do you respond to a ZPIC audit notice?

On Behalf of | Jul 29, 2022 | federal offenses | 0 comments

Texas medical providers are finding themselves at the center of ZPIC audits more and more often. Federally charged with preventing medicare fraud and overpayments, these audits serve an important function but can be unnerving to those subjected to one.

Responding properly to a ZPIC audit notice can help you avoid further complications.

What is ZPIC?

Federal contractors conduct Medicare Zone Program Integrity Contractors audits (ZPIC audits) under the direction of the Centers for Medicare and Medicaid Services. They work to uncover fraudulent billings under Medicare and Medicaid.

CMS has recently changed to Unified Program Integrity Contractors (UPIC), but ZPIC are still operating and the terms are being used interchangeably.

How should you respond to an audit notice?

The first step is to take the notice seriously. Read your audit notice carefully and note what is being requested of you. If ZPIC requests medical records, be sure to send complete files and include explanatory notes when necessary. Be sure to respond to the notice promptly.

Why are ZPIC audits so stressful?

ZPIC audits are confusing and often come as a surprise. These procedures are not well defined by the law, and the process and outcome can be unpredictable.

Can you appeal an unfavorable ZPIC audit?

There is a five-stage appeal process if your ZPIC audit yields unfavorable results.

  1. Redetermination
  2. Reconsideration
  3. Administrative hearing
  4. Medicare Appeals Council review
  5. Appeal in Federal District Court

This process can take well over a year and can be ponderous.

If you receive a ZPIC audit notice, respond carefully and within the requested timeframe. Providing a complete response can help you avoid further complications.