Oberheiden & McMurrey, LLP
Former Medicare Prosecutors & Defense Counsel
Audits performed by Zone Program Integrity Contractors (ZPICs) are important matters that can have serious, long-lasting consequences for your healthcare company and for you individually.
Why are ZPIC Audits Important?
Unlike some other audits, ZPIC benefit integrity audits are almost never random. ZPICs investigate potential fraud. Your company may have been identified through data analysis (showing that it had anomalously high billing for certain procedures). There may have been a complaint received by the U.S. Department of Health and Human Services’ Office of the Inspector General, by the ZPIC, or by other government agencies or contractors, or your company may have come to the attention of the ZPIC through other means. Regardless of how your company came to the attention of the ZPIC, you can be confident that the ZPIC auditor believes that there is a problem, and the auditor probably already has a good idea what that problem is.
The ZPIC auditor is there to confirm that their suspicions are correct and then to determine whether it was a simple mistake or the result of fraud. If the ZPIC determines that fraud occurred, it may refer the matter to the U.S. Attorney’s Office for criminal investigation. A criminal investigation can be life altering for the individuals involved, and even an investigation that results in acquittal or where no indictment occurs can bankrupt the healthcare company involved.
What to Do
Because ZPIC audits can have such serious consequences, it is important to act quickly and carefully. The first and most important step is hiring the right counsel. You need attorneys with experience in the field who know what to do and how to advocate on your behalf. Dealing with a ZPIC audit and potentially with a civil or criminal investigation is very different from handling other legal matters, even those in the healthcare field. The sooner you engage counsel the better, because the ZPIC has a head start: before you are even aware of the audit, it has already identified potentially problematic claims and may have already formulated a theory of liability. The more time you give your defense attorney to catch up, the better off you will be.
While each case is unique, there are a few common actions that most experienced counsel will take during the course of a ZPIC audit. The first is controlling and limiting your communications with ZPIC auditors. Generally, statements made to any investigators are much more likely to hurt your case than to help it, particularly in early stages before you understand the full nature of the theories against you. An attorney can provide some important insulation between the company and the ZPIC auditor that will allow you to get and give information about the matter without making any statements that could be used against you.
Second, your healthcare fraud attorney will likely assist you in performing your own analysis of the claims that are being reviewed by the ZPIC. It is often possible to form a clear vision of the ZPIC’s concerns by reviewing the claims it requests. This can reveal patterns in the type of procedure, timeframe, codes, and other features of the claim that will show the ZPIC’s focus. It may also reveal necessary changes in your billing practices that can be made immediately to improve your case.
Finally, your attorney will help you develop a plan and engage in effective negotiations to resolve the matter. Assuming that the ZPIC finds some overpayment, there are a number of important decisions that you will need to make. You will have to decide whether to appeal the determination and attempt to prevent recoupment. You will also want to determine whether a criminal referral is likely, and your attorney’s first priority in recommending changes to your policies and procedures and in discussions with the ZPIC should be preventing such a referral.
We Can Help You
The Oberheiden Law Group has an impeccable track record when it comes to resolving civil matters and avoiding criminal penalties in healthcare fraud cases. In addition to dealing with ZPIC matters, our team has successfully defended business owners, healthcare executives, and medical professionals in cases involving the Federal Bureau of Investigation (FBI), the Medicaid Fraud Control Unit (MFCU), the Office of Inspector General (OIG), the Department of Justice (DOJ), the Department of Defense (DOD), the Internal Revenue Service (IRS), and other law enforcement agencies.
- As a former Assistant United States Attorney, Lynette Byrd has years of experience working in law. She focuses her practice on criminal and civil litigation, Medicare and insurance audits, and general advice and counseling within the realm of healthcare law. Clients of Attorney Byrd have great respect for her ability to merge her profound law understanding with her superb litigation skills.
Call us today and speak to one of our experienced attorneys directly. We are available to discuss your situation in a free and confidential call, including on weekends.