Medicare fraud and abuse prevention and detection efforts are about to get tougher because of the new Zone Program Integrity Contractors (ZPIC). According to CMS, ZPICs were developed to fix flaws in the current Medicare program integrity system, which protects the Medicare program by preventing and detecting fraud and abuse. VGM’s Mark Higley has compiled an excellent document to understand the program titled “ZONE PROGRAM INTEGRITY CONTRACTORS AND AUDITS - Preparing for an Audit, How to Respond to a Review & FAQs”.
Summary: In conjunction with CMS' audit, oversight, and anti-fraud, waste, and abuse efforts, contracts are being awarded to independent vendors called “zone program integrity contractors”, or ZPICs. The ZPIC contractors will audit providers and suppliers of Part A, Part B, Part C, the Medicare prescription drug benefit (Part D), durable medical equipment, prosthetics, and orthotics supplier (DMEPOS), home health and hospice, and Medicaid services.
ZPICs will cover seven zones based on Medicare administrative contractors (MAC) jurisdictions. There are five “hot spot” zones: California, Florida, Illinois, New York and Texas. These “hot spots” align with Program Integrity field offices. There are two other zones covering states with limited incidence of fraud. The Contractors are organizations hired indirectly (or in connection with other CMS affiliated contractors) by CMS to perform a wide range of medical review, data analysis and Medicare evidence-based policy auditing activities. As of 1/2010, CMS has awarded only three of the seven ZPIC contracts
- Health Integrity LLC for Zone 4 (Colorado, New Mexico, Oklahoma, and Texas)
- Advance Med for Zone 5 (Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia, and West Virginia) —
- SafeGuard Services LLC for Zone 7 (Florida, Puerto Rico, and Virgin Islands.
The full document may be accessed by clicking here.
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