With increasing transparency in healthcare, exposing fraud and abuse is a big issue. One of the “watchdog” entities is known as a Zone Program Integrity Contractor (ZPIC). Let’s take a look at their role.
The primary goal of the ZPIC is to:
- identify cases of suspected fraud
- develop them thoroughly and in a timely manner
- take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped.
All cases of potential fraud are referred to the Office of Inspector General (OIG), Office of Investigations field office (OIFO) for consideration and initiation of criminal or civil prosecution, civil monetary penalty, or administrative sanction actions.
Preventing and detecting potential fraud involves a cooperative effort among beneficiaries, providers, quality improvement organizations (QIOs), state Medicaid fraud control units (MFCUs), and Federal agencies such as CMS, the Department of Health and Human Services (DHHS), OIG, the Federal Bureau of Investigation (FBI), and the Department of Justice (DOJ). As opposed to RAC contractors who audit claims, ZPIC contractors have a broader scope of responsibilities in investigating what constitutes fraud.
Examples of Medicare Fraud
The most frequent kind of fraud arises from a false statement or misrepresentation made, or caused to be made, that is material to entitlement or payment under the Medicare program.
Fraud may take such forms as:
- Incorrect reporting of diagnoses or procedures to maximize payments.
- Billing for services not furnished and/or supplies not provided. This includes billing Medicare for appointments that the patient failed to keep.
- Billing that appears to be a deliberate application for duplicate payment for the same services or supplies, billing both Medicare and the beneficiary for the same service, or billing both Medicare and another insurer in an attempt to get paid twice.
- Altering claim forms, electronic claim records, medical documentation, etc., to obtain a higher payment amount.
- Soliciting, offering, or receiving a kickback, bribe, or rebate, e.g., paying for a referral of patients in exchange for the ordering of diagnostic tests and other services or medical equipment.
- Unbundling or “exploding” charges.
These are but a few of the circumstances where provides could get into hot water.
ZPIC is responsible for preventing, detecting, and deterring Medicare fraud. They:
- Prevent fraud by identifying program vulnerabilities.
- Proactively identify incidents of potential fraud that exist within its service area and takes appropriate action on each case.
- Investigate allegations of fraud made by beneficiaries, providers, CMS, OIG, and other sources.
- Explore all available sources of fraud leads in its jurisdiction.
- Initiate appropriate administrative actions to deny or to suspend payments that should not be made to providers where there is reliable evidence of fraud.
- Refer cases to the Office of the Inspector General/Office of Investigations (OIG/OI) for consideration of civil and criminal prosecution and/or application of administrative sanctions.
ZPIC units pursue leads through data analysis, the Internet, the Fraud Investigation Database (FID), news media, etc. They shall take prompt action after scrutinizing billing practices, patterns, or trends that may indicate fraudulent billing.
Cases with the greatest program impact/and or urgency are given the highest priority. Allegations or cases having the greatest program impact would include cases involving:
- Patient abuse or harm.
- Multi-state fraud.
- High dollar amounts of potential overpayment.
- Likelihood for an increase in the amount of fraud or enlargement of a pattern.
- Fraud complaints made by Medicare supplemental insurers.
- Law enforcement requests for assistance that involve responding to court- imposed deadlines.
- Law enforcement requests for assistance in ongoing investigations that involve national interagency initiatives or projects.
The ZPIC units are secretive and secure in their operations. Information is shared on a need-to-know basis. Strict procedural requirements are in place. In fact a security officer is empowered to take such action as is necessary to correct breaches of the security standards and to prevent recurrence of the breaches. In addition, the security officer documents the action taken and maintains that documentation for at least 7 years.
Background and character reference checks, including at a minimum credit checks, for potential employees to verify their suitability for employment are required with more extensive investigations warranted depending on security clearance level.
It is important for providers to understand the serious nature of this unit and what they investigate. Providers can then safeguard and protect themselves by making sure their operations are compliant in all areas of the law.