25.2 C
Lagos
Tuesday, October 20, 2020

Medicare Fraud Prevention – A Look at ZPIC Audits

- Advertisement -

Zpic in full stands for Zone Program Integrity Contractor or Contractors. Zpic Audit refers to an investigation carried out by a Zpic who is an authorized government contractor. These contractors work under the 1996 Health Insurance Portability and Accountability Act and the 2003 Medicare Modernization Act.

- Advertisement -

Their role is protecting the integrity of Medicare claims by Investigating and reporting on Medicare fraud. This is basically an audit to identify whether or not any fraud has been committed by a healthcare professional, office or facility. So these government contractors carry out an investigation only after they identify a potential fraud case.

These contractors work under a recovery program dubbed fee for service which enables them to get paid for recouping payments and successfully denying future payments that violate the Medicare billing regulations.

Centre for Medicare and Medicaid services is the umbrella body under which Zpic falls mandated to identify, detect and help prevent fraud or abuse.

Medicare Fraud

Medicare fraud claims can be classified as abusive, wasteful or fraudulent. Examples of Medicare Fraud Making a claim when there is no service rendered or when the service is provided by an unlicensed physician

Giving or Accepting Kickbacks

This refers to making a claim for a beneficiary who is not approved prescription fraud for example a doctor prescribing medication for a family member or making claims without the necessary supporting documents.

Fraud committed by a patient who consults several doctors within a short period of time also referred to as Doctor shopping; making claims with false price reports such as samples and free products claims Zpic is operational in seven zones namely Safeguard services, AdvanceMed, Cahaba, Health Integrity, AdvanceMed, Under Protest and SafeGuard services that are inclusive of all the fifty US states as well as Puerto Rico, American Samoa, Us Virgin Islands, Guam, and Mariana Islands.

What It Means To a Health Provider Selected For a Zpic Audit

If a health provider is due for a Zpic audit it means that they are subject to a fraud investigation or the contractors are reviewing information on claims made to identify whether a fraud investigation should be opened.

Possible Consequences of a Zpic Audit

The most serious consequences is the audit case being escalated to law enforcement agencies for criminal prosecution or civil litigation in accordance with the False claims Act and the imposition of sanctions such as civil monetary penalty.

The results can be referred to the Medicare administrative contractors to collect the overpayment demand. However the health provider has the right to appeal through the five step Medicare appeal process. The third consequence is the best of the three as it requires no legal action. This is when the contractors determine that provider education would suffice to resolve the case.

- Advertisement -

The Importance of Legal Counsel

As noted above a Zpic audit can lead to serious legal consequences. The legal consequences could cost you your license as a health care provider so it is not only necessary to have a legal team but also to notify them and involve them early in the process.

The legal team can advise you on your rights and obligations, advise your employees on what to say or do not to say, communicate with the auditors on your behalf. The legal team will help execute the best defense strategy to omit your disclosures so you only provide the necessary information to resolve the audit in your favor and with speed.

They can also help you challenge Zpic audit findings before the final determination is issued by focusing on identifying issues with the auditors methods, assumptions and conclusions so they resolve the case favorably without the need to file an appeal or deal with further federal investigation.

In conclusion, health care fraud is vast and can be occur in subtle or complex ways. It is not easy to determine what Zpic considers as fraud and how you can avoid falling victim to fraudulent claims. Additionally it is difficult to assess whether or not fraud occurred and yet it is necessary for medical facilities to understand and adhere to Medicare guidelines at all times. Since to be for-warned is to be forearmed, health care practitioners should seek qualified legal advice on compliance measures.

Medicare Fraud
  • Save

Disclaimer: This article is purely informative & educational in nature and should not be construed as medical advice. Please use the content only in consultation with an appropriate certified medical or healthcare professional.

Editor
Editorial Staffs at Healthtian, A team of Writers.
- Advertisement -

Trending Now

5 Reasons You Should Never Take Medication Without a Prescription

Sexual health issues like erectile dysfunction can be embarrassing to deal with. It’s one thing to take a trip to the doctor’s office to...
- Advertisement -

Skin Rashes: Causes, Symptoms and Effective Home Remedies

Skin rashes are common skin problems experienced by millions of people worldwide; it is characterized by a visible change in the color...

Is Male Menopause a Thing?

The term menopause doesn't only typically relate to women, and it also refers to men as well. Yes, there is something known...

How to Increase Sodium Levels in Your Blood?

Levels of sodium in the blood is often a misunderstood topic and it is extremely necessary that we as individuals understand the meaning and...

Atis Fruit: 10 Health Benefits of Eating Sugar Apple

Sugar apple (Atis fruit), is the Annona squamosa fruit belonging to the natives of West Indies and to the tropical Americas like Peru, Mexico,...

7 Types of Disability and Examples

For disabled people life is a lot different than the rest of us. They don’t lead normal lives like we do and need assistance...

Spider Bites: Symptoms, Treatment & Identification

Spider bites in the United States are often annoying but they are rarely fatal. If a person gets bitten by a black...

Women Celebrating #nobraday 2019 on Social Media (Pics)

Today is #nobraday so our team will scout social media and bring you tweets and posts across social media platforms on how women and...

Do You Get Sick After Getting the Flu Shot? Here Is Why

This is the period of winter and Harmattan. Yes, it is the holiday period, but it is also the period where almost everyone gets...

Friends

Newsletter

Nurture yourself with health tips, wellness advice, and more.

- Advertisement -

Related Posts

Look After your Eyes and Keep the Clear Vision For Longer

Nowadays, people tend to be more concerned about the way they look. They go to the gym, eat particular foods, drink gallons of mineral...

World AIDS Day – All You Should Know & Frequent Questions Answered

People all over the world observed the 31st annual World AIDS Day on Sunday the 1st of December. The World Aids day is an event that...

Giardia Infection (Giardiasis) – Symptoms, Causes and Treatment

Giardiasis is an infection that is caused by a microscopic parasite known as “Giardia lamblia” in the intestine. It can be contracted when a...

Heads Up – 5 Most Common Workplace Injuries

You go to work every day, but the thought that something might happen to you while you’re at the office or on the company’s...

LEAVE A REPLY

Please enter your comment!
Please enter your name here

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Medicare Fraud
Copy link
Powered by Social Snap