The Zone Program Integrity Contractors (ZPICs) and Unified Program Integrity Contract Jurisdiction 1 (UPIC J1) are used to perform fraud and abuse investigations, support benefit integrity efforts, provide medical review support, national and regional data analysis, and law enforcement support.
What is a zone protection integrity contractor?
It’s no secret that government-provided health coverage is sometimes targeted by fraudsters. Zone Protection Integrity Contractors are one of several entities, created by the Centers for Medicare & Medicaid Services (CMS), charged with finding and putting an end to these cases of fraud.
Are program integrity contractors protected from criminal or civil liability?
As a result, program integrity contractors (such as ZPICs), their employees, and professional consultants are typically protected from criminal or civil liability as a result of the activities they perform under their contracts as long as they use due care .
What states are covered by safeguard Zone 1?
Zone 1 – SafeGuard Services: California, Hawaii, Nevada and the territories of American Samoa, Guam, the Northern Mariana Islands, Palau, the Marshall Islands and the Federal States of Micronesia. Zone 2 – AdvanceMed (an NCI Company): Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming.
Which of the following is a responsibility of Medicaid integrity Contractors?
CMS has broad responsibilities under the Medicaid Integrity Program to: Hire contractors to review Medicaid provider activities, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issues.
What is the responsibility of the national benefit integrity Medicare Drug integrity Contractor?
National Benefit Integrity (NBI)-Medicare Prescription Drug Integrity Contractor (MEDIC), General Support System(GSS) is used to perform fraud and abuse investigation, support benefit integrity efforts, provide medical review support, national and regional data analysis, and law enforcement support.
Which of the following is a responsibility of Medicaid integrity Contractors MICs )? Quizlet?
Medicaid Integrity Contractors) Review Medicaid claims to determine potential provider waste or abuse, identify overpayments, and provide education to providers on payment integrity and quality of care issues.
What is the role of the Center for Program integrity?
At the Center for Program Integrity (CPI), our mission is to detect and combat fraud, waste and abuse of the Medicare and Medicaid programs. We do this by making sure CMS is paying the right provider the right amount for services covered under our programs.
What is a unified program integrity contractor?
UPICs were created to perform program integrity functions for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice, Medicaid and Medicare-Medicaid data matching.
What is ZPICs?
Zone Program Integrity Contractors (“ZPICs”) are defined as companies that are contracted by the Centers for Medicare and Medicaid Services (“CMS”) to conduct detailed and investigative audits of health care providers.
What is the goal of the Medicare integrity Program MIP?
The overall goal of the provider audits is to identify overpayments and to ultimately decrease the payment of inappropriate Medicaid claims.
What does Program integrity mean?
Program integrity can be defined as a federal, state, or local government agency's ability to fulfill its mission while addressing fraud, waste, and abuse (FWA). It focuses on streamlining processes to optimize the resources allocated to the program.
What is the Medicare integrity Program quizlet?
Section 1936 of the Social Security Act created the Medicaid Integrity Program (MIP) and directed the CMS to enter into contracts to review Medicaid provider actions, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issues.
Which of the following contractors are a part of the national group of Program integrity Contractors?
National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC) Railroad Retirement Board (RRB) CMS contractors (FPS, PIMAS, Acumen, IBM) MAC Medical Review Units associated with MPIP.
Which of the following is considered the best defense under the Medicare integrity Program quizlet?
Which of the following is considered the best defense under the Medicare Integrity program? Having a strong compliance plan.
Who is responsible for overseeing the Medicare compliance program?
One of the key elements in the Medicare compliance program is the creation of a Compliance Committee, referred to as the Health Plan Compliance Council, which is charged with supporting the Medicare Compliance Officer (“MCO”) in review and oversight of the Medicare compliance program.
What is Medicare administrative contractors?
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
What is Medicare Program integrity Manual?
The Medicare Program Integrity Manual contains the policies and responsibilities for contractors tasked with medical and payment review.
What triggers a ZPIC audit?
Automated ZPIC Audits These audits typically result from ZPICs' data analytics rather than external triggers. During an automated audit, ZPIC personnel simply review the provider's billing data and then issue a determination.
What organization is responsible for bringing together the Medicare and Medicaid program integrity groups under one management structure?
The Center for Program Integrityhtml ▪ Provider and Beneficiary Education 16 Page 21 The Center for Program Integrity brings together the Medicare and Medicaid program integrity groups under one management structure to strengthen and better coordinate existing and future activities to prevent and detect fraud, waste, and abuse.
What is a Upick audit?
Unified Program Integrity Contractors (UPIC) Audits Goal The Centers for Medicare and Medicaid Services (CMS) created the UPIC audits to identify and stop fraud and abuse in Medicare and Medicaid. The main goal of UPIC is to help CMS: Find fraud, abuse, and waste. Perform regional Medicare and Medicaid data analysis.
What is the purpose of recovery audit contractors?
What does a Recovery Audit Contractor (RAC) do? RAC's review claims on a post-payment basis. The RAC's detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments.
How long does a Upic audit take?
Three monthsThe UPIC Audit is different than the TPE audit. I suggest you familiarize yourself with both. How long did the process take? Three months for each audit.
Can a provider disregard an auditor's request for records for a cert review?
Can a provider disregard an auditor's request for records for a CERT review? Response Feedback: If records are not submitted when a request is received, it will result in an automatic finding for "no documentation".
What organization is responsible for bringing together the Medicare and Medicaid program integrity groups under one management structure?
The Center for Program Integrityhtml ▪ Provider and Beneficiary Education 16 Page 21 The Center for Program Integrity brings together the Medicare and Medicaid program integrity groups under one management structure to strengthen and better coordinate existing and future activities to prevent and detect fraud, waste, and abuse.
What is Medicare administrative contractors?
A Medicare Administrative Contractor (MAC) is a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.
What is an FDR for Medicare?
First Tier, Downstream, and Related Entities (FDRs) are defined by CMS as any party that enters into a written arrangement with a Medicare Advantage organization or Part D plan sponsor to provide administrative services or healthcare-related services.
Can a provider disregard an auditor's request for records for a cert review?
Can a provider disregard an auditor's request for records for a CERT review? Response Feedback: If records are not submitted when a request is received, it will result in an automatic finding for "no documentation".
What is Medicare Integrity Program?
This program was established in an effort to strengthen CMS’s ability to reduce fraud and abuse in the Medicare program. Under MIP, CMS began transferring much of the responsibility for detecting and deterring Part A and Part B fraud and abuse to Program Safeguard Contractors (PSCs). Duties and responsibilities of the PSCs included, but were not limited to:
What is a ZPIC audit?
Once a provider or supplier has been identified as a potential target for audit, there are a number of investigative methods that may be used by a ZPIC. In almost every case, an analysis of the provider’s claims or billing practices will be conducted. ZPICs will also typically verify the license of any physician, nurse practitioner, physician assistant, nurse, therapist or other licensed professional whose services are being billed to the Medicare program. CMS has expressly directed ZPICs to exercise discretion when interviewing Medicare beneficiaries. As set out in the Medicare Program Integrity Manual:
What is the role of ZPIC?
ZPIC Responsibilities: As CMS has described its role, the “ZPIC is responsible for preventing, detecting, and deterring fraud, waste and abuse in both the Medicare program and the Medicaid program through the collaboration of the Medicare-Medicaid Date Match Program (Medi-Medi).”.
When was ZPIC signed into law?
I. Background of the ZPIC Program: On December 8, 2003, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) was signed into law. Under this legislation:
What states are in Zone 1?
Zone 1 – SafeGuard Services: California, Hawaii, Nevada and the territories of American Samoa, Guam, the Northern Mariana Islands, Palau, the Marshall Islands and the Federal States of Micronesia.
Is a MIP contractor a criminal?
(a) A MIP contractor, a person or an entity employed by, or having a fiduciary relationship with, or who furnishes professional services to a MIP contractor is not in violation of any criminal law or civilly liable under any law of the United States or of any State (or political subdivision thereof) by reason of the performance of any duty, function, or activity required or authorized under this subpart or under a valid contract entered into under this subpart, provided due care was exercised in that performance and the contractor has a contract with CMS under this subpart .”
Jurisdiction of a ZPIC in the United States
ZPICs are a specific category of entities that investigate potential fraud cases relating to Medicare Parts A and B, as well as prosthetics, orthotics, supplies, and home hospice care.
Functions of a ZPIC
As you might guess, a ZPIC’s duties include more than just requesting documentation. ZPICs primarily investigate cases where fraud, waste, or abuse are suspected. They also provide support to victims of identity theft relating to Medicare services, which includes helping health care providers recoup expenses lost due to fraudulent claims.
What to Expect During a ZPIC Audit
ZPIC audits are often complex, but are performed simply to investigate the organization. During investigations, ZPICs are likely to request copies of all medical records and documentation, visit the provider site, and conduct interviews. For medical organizations and facilities, payments could be withheld if deemed appropriate by the investigator.
ZPIC Audit Attorneys at Oberheiden, P.C
Even if you don’t think you have done anything wrong, it’s in your best interests to let an experienced ZPIC audit attorney navigate the process on your behalf. ZPIC audits can be more complicated than you think and require an experienced legal team to make sure you get the best possible outcome.
What is ZPIC in Medicare?
If you’re reading this article it’s probably because you or your medical office has received a letter from a Zone Program Integrity Contractor (“ZPIC”) for The Centers for Medicare & Medicaid Services (“CMS”) alleging that you may have improperly billed Medicare for the provision Medicare Services to your patients.
How many ZPIC zones are there?
There are seven ZPIC zones. It is possible for providers to hear from more than one ZPIC since the seven ZPICs focus on different aspects of the Medicare program. ZPIC Zone 7 includes Florida, Puerto Rico, and the U.S. Virgin Islands in its geographic scope. The Zone 7 – Zone Program Integrity Contractor was established to identify, research, and investigate cases of Medicare Program fraud relating to Parts A and B, DMEPOS, home health and hospice, and claims for dually eligible Medicare and Medicaid recipients. Fraud may include:
Will ZPIC audit my claims?
There is a significant chance that one or more of your claims will be audited in the future by a ZPIC. ZPICs have been aggressively reviewing and investigating provider and supplier medical records to identify improper billing and payments. Most providers and suppliers are identified for audit and/or investigation through an analysis of their billing practices. Our firm recommends that you consult with an experienced Healthcare Attorney if you are being audited by CMS’s Zone Program Integrity Contractors or if you have been placed on any type of corrective action. Contact us so that we can create a defense against the allegations while ensuring that you comply with the audit investigation.
Jurisdiction of A ZPIC in The United States
Functions of A ZPIC
- As you might guess, a ZPIC’s duties include more than just requesting documentation. ZPICs primarily investigate cases where fraud, waste, or abuse are suspected. They also provide support to victims of identity theft relating to Medicare services, which includes helping health care providers recoup expenses lost due to fraudulent claims.
What to Expect During A ZPIC Audit
- ZPIC audits are often complex, but are performed simply to investigate the organization. During investigations, ZPICs are likely to request copies of all medical records and documentation, visit the provider site, and conduct interviews. For medical organizations and facilities, payments could be withheld if deemed appropriate by the investigator. This can become costly. ZPICs do not ha…
ZPIC Audit Attorneys at Oberheiden, P.C.
- Even if you don’t think you have done anything wrong, it’s in your best interests to let an experienced ZPIC audit attorney navigate the process on your behalf. ZPIC audits can be more complicated than you think and require an experienced legal team to make sure you get the best possible outcome. Don’t make a costly mistake by putting your business in the wrong person’s h…