Zone Program Integrity Contractors (zpics), Zone Program Integrity Contractors (zpics)

Zone Program Integrity Contractors (ZPICs),

• Zone Program Integrity Contractors (ZPICs),

• 2013 TEXAS HEALTH CARE ASSOCIATION

• SUMMER MEETING

ZPICs were called Program Safeguard Contractors (PSCs)

• ZPICs were called Program Safeguard Contractors (PSCs)

• 7 Zones:

• Texas, Colorado and Oklahoma are in Zone 4
• Health Integrity is the ZPIC for Zone 4

• Contractor paid fixed rate ($84,928.432.00), but may receive bonus for quality

• CMS paid over one half of a billion on ZPIC contracts

ZPIC reviews the following programs:

• ZPIC reviews the following programs:

• Medicare Part A—Hospitals, Home Health, and Hospice
• Medicare Part B—Fee-For-Service, Office Visits, X-Rays, Blood Tests, Ambulance Services, etc.
• Durable Medical Equipment (DME)
• Medicare Medicaid Data Match Project—Partnership between state Medicaid agencies, CMS, and law enforcement officials to identify improper Medicare and Medicaid billing and utilization patterns

ZPIC tasks:

• ZPIC tasks:

• Performing Data Analysis and Data Mining
• Conducting Medical Reviews in Support of Benefit Integrity
• Supporting Law Enforcement and Answering Complaints
• Investigating Fraud and Abuse
• Recommending Recovery of Federal Funds through Administrative Action
• Referring Cases to Law Enforcement

Examples of ZPIC abuses against providers:

• Examples of ZPIC abuses against providers:

• Deficient ZPIC Auditor Qualifications
• Auditors are not required to have any experience in the medical, therapeutic, or nursing professions
• “Lack of medical necessity” determinations by auditors not reviewed by physicians or persons with a health care background
• Restrictions on Presence of Attorney or Corporate Officer
• Audits are scheduled unannounced and auditors insist on employee interviews without allowing attorneys or corporate officer time to get to facility to monitor employee interviews

Review usually starts based on data with CMS

• Review usually starts based on data with CMS

• Can arrive on very short notice (1 hour or less)

• Unlimited number of records can be reviewed

• Can put provider on 100% payment review