ED Coding and Reimbursement Alert

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 the Center for Program Integrity'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.

The ZPIC review may also lead to a carrier decision to perform extrapolation resulting in large take backs

In performing these functions, ZPICs may, as appropriate:

• Request medical records and documentation;
• Conduct an interview;
• Conduct an onsite visit;