Zone Program Integrity Contractor (ZPIC)
Zone Program Integrity Contractors (ZPICs) were created to perform program integrity functions in these zones for Medicare Parts A, B, Durable Medical Equipment Prosthetics, Orthotics, and Supplies, Home Health and Hospice and Medicare-Medicaid data matching. Medicare Part C and D program integrity efforts are handled separately by one national contractor known as the Medicare Drug Integrity Contractor (MEDIC). The ZPICs and the MEDIC work under the direction of the Center for Program Integrity (CPI) in CMS.
The below table lists all of the ZPICs and their zones.
|ZPIC||Safeguard Services (SGS)||AdvanceMed||Cahaba||Health Integrity||AdvanceMed||Under Protest||Safeguard Services (SGS)|
|States in Zone||CA, HI, NV, AS, GU, MP||WA, OR, ID, UT, AZ, WY, MT, ND, SD, NE, KS, IA, MO, AK||MN, WI, IL, IN, MI, OH, KY||CO, NM, TX, OK||AR, LA, MS, TN, AL, GA, NC, SC, VA, WV||PA, NY, DE, MD, DC, NJ, MA, NH, VT, ME, RI, CT||FL, PR, VI|
The primary goal of ZPICs is to investigate instances of suspected fraud, waste, and abuse. ZPICs develop investigations early, and in a timely manner, take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid. They also identify any improper payments that are to be recouped by the MAC. Actions that ZPICs take to detect and deter fraud, waste, and abuse in the Medicare Program include:
- Investigating potential fraud and abuse for CMS administrative action or referral to law enforcement;
- Conducting investigations in accordance with the priorities established by CPI's Fraud Prevention System;
- Performing medical review, as appropriate;
- Performing data analysis in coordination with CPI's Fraud Prevention System;
- Identifying the need for administrative actions such as payment suspensions and prepayment or auto-denial edits; and,
- Referring cases to law enforcement for consideration and initiation of civil or criminal prosecution.
In performing these functions, ZPICs may, as appropriate:
- Request medical records and documentation;
- Conduct an interview;
- Conduct an onsite visit;
- Identify the need for a prepayment or auto-denial edit and refer these edits to the MAC for installation;
- Withhold payments; and,
- Refer cases to law enforcement.
ZPICs also support victims of Medicare identity theft. A provider or supplier who believes that he/she may have had their provider information stolen and used to submit Medicare claims for which payment was made can request that the ZPIC for their zone investigate the case. The ZPIC will then work with CMS to determine the appropriate remedial action to assist the provider. See the CMS Provider Victim Validation/Remediation Initiative - Medicare Program Integrity Contractor Points of Contact for guidance on how to avoid and report Medicare identity theft and information on current scams.
The following are some of the major functions that the ZPICs do not perform. These functions are performed by the MAC:
- Claims processing, including paying providers/suppliers;
- Provider outreach and education;
- Recouping monies lost to the Trust Fund (the ZPICs identify these situations and refer them to the MACs for the recoupment);
- Medical review not for benefit integrity purposes;
- Complaint screening;
- Claims appeals of ZPIC decisions;
- Claim payment determination;
- Claims pricing; and
- Auditing provider cost reports.
Fraud frequently arises from false statements or misrepresentations made that are material to entitlement or payment under the Medicare Program. A violator may be a provider, a beneficiary, or an employee of a provider or some other business entity including a billing service. Providers have an obligation, under law, to conform to the requirements of the Medicare Program. Fraud committed against the program may be prosecuted under various provisions of the United States Code and could result in the imposition of restitution, fines, and, in some instances, imprisonment. In addition, a wide range of administrative sanctions (such as deactivation or revocation of Medicare enrollment or billing privileges, suspension of payments, or exclusion from participation in the Medicare Program) and civil monetary penalties may be imposed when facts and circumstances warrant such action. An investigation that demonstrates potential fraud may be referred to law enforcement for further investigation.
Contacts for Reporting Potential Fraud
Providers as well as Beneficiaries are encouraged to report fraud directly to the Department of Health and Human Services (DHHS) Office of Inspector General (OIG) Hotline at 1-800-HHS-TIPS (1-800-447-8477).
Last Updated May 14, 2018