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
