ZPIC AuditsIs Your Practice Being Audited by a ZPIC? Did You Know it Can Lead to an OIG Exclusion?

Zone Program Integrity Contractors (ZPICs) are among the most aggressive program integrity entities employed by the Centers for Medicare and Medicaid Services (CMS).  As most healthcare providers are aware, ZPICs regularly place physician practices on prepayment review and sometimes conduct post payment audits of previously paid claims.  However, did you know that ZPICs are also supposed to play a role when it comes to “exclusions”

According to Sec. of the Medicare Program Integrity Manual (MPIM) reflects, ZPICs are actually REQUIRED by CMS to review and evaluate cases to determine if they warrant exclusion action.  And if in its estimation exclusion is warranted, they must make a recommendation to the Office of Inspector General (OIG) for consideration.

Section 2.2 lists a number of examples of the types of cases that would be suitable for the ZPIC to make an exclusion recommendation.  Some of them, such as convictions of program related offenses under (§1128(a)) and convictions related to patient abuse or the sale and use of drugs (§1128(b) are common sense and would likely have already resulted in the initiation of an exclusion action, but a number of others may surprise you.  Below you will find a partial list:
  • Providers who have a pattern of adverse QIO, AC, or MAC findings.
  • Providers whose claims must be reviewed continually and are subsequently denied because of repeated instances of overutilization.
  • Providers who have been the subject of previous cases that were not accepted for prosecution because of the low dollar value.
  • Providers who furnish or cause to be furnished items or services that are substantially in excess of the beneficiary’s needs or are of a quality that does not meet professionally recognized standards of health care (whether or not eligible for benefits under Medicare, Medicaid, title V or title XX).
  • Providers who are the subject of prepayment review for an extended period of time (longer than 6 months) who have not corrected their pattern of practice after receiving educational/warning letters.
ZPICs that make exclusion recommendations are required to consider a number of factors and are supposed to consider alternatives in an effort to change the provider’s conduct.  And, of course, the final authority to exclude a provider from participation in Federal health benefits programs lies with the OIG.  But it is important for you to keep in mind that this is yet another risk area your practice may face in the event of a ZPIC audit. 

Unfortunately, this is only one of the additional risks that your practice may face.  For additional information on ZPIC audits, we recommend you review the recent article by Robert W. Liles entitled “UPIC / ZPIC Referrals to State Licensure Boards, Professional Societies, State Surveyors, QIOs and to the OIG for Exclusion Consideration.”  it provides a nice preview on inter-agency referrals of complaints by ZPICs. 

Have more questions about exclusions? Call Exclusion Screening at 1-800-294-0952 or fill out the form below to have your questions answered and to hear how Exclusion Screening can help you!

About the AuthorCo-Founder, Exclusion Screening
Paul Weidenfeld is a long time health care lawyer who has specialized in litigation arising out or, or relating to healthcare fraud and the False Claims Act. A former federal prosecutor and National Health Care Fraud Coordinator for the Department of Justice, Paul is a frequent speaker who has earned recognition both as a Federal Prosecutor and as a member of the private bar.  Paul is also a co-founder of 
Exclusion Screening, LLC, a company that offers providers a simple, cost-effective way to meet their exclusion screening obligations.