Groups » Worried about ZPIC Audit? Here’s What You Need to Know

Medicare and Medicaid fraud is on the rise. In fact, more than $4.7 billion were obtained in settlements and judgments from civil cases involving fraud and false claims by the Department of Justice in the fiscal year 2016 ending 30th September. This is the third highest annual recovery in False Claims Act history.

The Centers for Medicare and Medicaid Services (CMS) has introduced the Zone Program Integrity Contractor (ZPIC) in order to detect and prevent fraud. ZPICs are responsible for ensuring the integrity of all parts of Medicare claims.

People misunderstand that ZPICs focus only on small players such as home-health agencies, hospices, and durable equipment providers. However, ZPICs swing into action when they suspect fraud and abuse. Therefore, everyone associated with providing Medicare and Medicaid should maintain honesty to stay away from ZPIC audits.

Why Hire a ZPIC Attorney?

ZPICs have the authority to review medical records, interview patients, conduct site visits, withhold payments, and also refer suspected Medicare fraud to law enforcement agencies. ZPICs work in coalition with the FBI and can raid medical providers’ offices and copy documents under the power of the federal government if they suspect fraud. Since ZPIC audits often result in Civil Monetary Penalties(CMP) and criminal charges can be brought against providers, hiring the right counsel is important.

If you believe you have managed your business ethically and never engaged in unscrupulous activities, then you must do everything to stay away from a ZPIC audit. This is because ZPIC audits can damage your reputation and cost you hundreds of dollars in penalties. Thus, you need to work with an attorney who has experience in handling ZPIC audits and can advocate on your behalf.

Attorneys with ZPIC experience can help practices during ZPIC audits and investigations. They can also educate medical providers and professionals about preparing for and reacting during a ZPIC audit and provide assistance with overpayment demands, Medicare appeals, and civil and criminal Medicare fraud proceedings. The attorney can further help you:

  • Communicate with ZPIC auditors

  • Perform your own analysis of the claims

  • Engage in effective negotiations to resolve matters brought forward by auditors

Choosing the Right ZPIC Attorney

Choosing an attorney for ZPIC audit appeal is different from choosing an attorney for other legal matters. You need to hire an attorney with experience in this specific area of law and one who has proven skills, talent, and expertise to successfully defend you. This is because the underlying rules of ZPIC audits are complex, and producing the wrong documents or information can get you into further trouble.

ZPICs can initiate proceedings against you even before you are aware of the audit. So it is best to start looking for a reputed and experienced attorney as soon as possible. Some factors to consider when looking for ZPIC attorneys are:

  • Number of ZPIC audits they have handled

  • The success rate

  • Knowledge of ZPIC audit procedure

  • Knowledge of the mistakes that should be avoided during ZPIC audit

  • Qualifications and certifications

It is best to get references from business associates or partners who have faced ZPIC audits. Hire the right ZPIC attorney and stay prepared for audits.

ZPIC Audit Mistakes to Avoid

The consequences of ZPIC audits can be severe, even harsher than the ones conducted by the RAC. It is important that you prepare yourself in advance and avoid making the common mistakes that can raise red flags. Some of the common mistakes made by Medicare providers and medical professionals are:

  • Not Maintaining Proper Documents:Proper documentation is key to getting through a ZPIC audit successfully. The inability to provide accurate information/documentation can make auditors believe that the documents do not exist or you are not willing to produce the documents due to noncompliance. Maintaining proper medical documentation will help you answer all the questions and make auditors believe that you are running the business ethically.

  • Overlooking the Importance of Self-Audit: Self-audits are important to avoid ZPIC investigations. Self-audits help you identify errors and mistakes in coding and billing, so you can get them corrected immediately. Moreover, providers that engage in self-auditing are looked upon as responsible individuals/entities by auditors. Involving an experienced attorney will help you perform effective internal audit and keep external auditors at bay. However, self-audits need to be performed regularly to keep the system updated.

  • Not Educating Employees:Educating employees on a regular basis is important to ensure they do not make mistakes when coding. Well-prepared written instructions that can be scrutinized by legal counsel should be provided to coders to ensure proper and accurate coding. Regular changes must also be implemented to the codes to ensure compliance.

  • Not Communicating Properly:Auditors do not want to tarnish your reputation intentionally; they do what they are supposed to do. So it is your responsibility to communicate properly and clear confusions. For instance, if you have outsourced the coding and billing to a third-party service provider and they made mistakes which led to the confusion, then you must communicate that the mistakes were not your fault. Even if the penalties are not absolved completely, the damages might be lessened.

By avoiding the above mistakes, you can save yourself from being investigated and avoid the harsh consequences of a ZPIC audit.


With increasing fraud and abuse of Medicare and Medicaid, ZPICs have become more proactive than ever. Therefore, everyone is under scrutiny and even the smallest mistake can raise red flags. So it is important to comply with the rules and regulations, and stay away from unscrupulous activities. However, if you have done nothing wrong then no one can harm you. Get legal counsel and save yourself from unnecessary trouble.


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