Can a ZPIC Audit Result in Medicare Fraud Charges?

Defense Attorneys Protecting Professionals from ZPIC Audit and Medicare Fraud Charges

Every year, Zone Program Integrity Contractors (ZPICs) conduct thousands of audits of Medicare claims. ZPICs work closely with the U.S. Attorney’s Office and their audits can result in civil or criminal Medicare fraud investigations. Because of this potential, ZPIC audits are very serious matters that need to be handled carefully and quickly.

What Is a ZPIC Audit?

ZPIC audits are medical reviews or benefit integrity reviews focused on identifying potentially fraudulent billing activity. ZPIC audits generally are not random. They arise because the ZPIC has identified potential fraud. ZPIC audits often result from data analysis bills for certain services compared to other local or national providers. A ZPIC audit can be provoked by a complaint, either to the U.S. Department of Health and Human Services’ Office of the Inspector General (HHS-OIG) or directly to the ZPIC, and, other government contractors may make referrals that result in a ZPIC audit. Regardless of the cause of an audit, the ZPIC will be looking for evidence of fraudulent Medicare billing, which can carry severe consequences.

Will the Results of a ZPIC Audit Be Shared with Prosecutors?

ZPICs cooperate with the HHS-OIG and the U.S. Attorney’s Office, and in addition to recommending administrative and civil actions including suspension of Medicare payments, recoupment of overpayments, pre- or post-payment review, program exclusion, and civil monetary penalties, a ZPIC auditor may refer a matter for criminal investigation.

The ZPIC may employ a variety of techniques to determine whether fraud has occurred and whether a matter is appropriate for criminal referral. In addition to analyzing claim data, ZPIC will likely request and review medical documentation for evidence of alteration or fabrication. It may also contact beneficiaries or related physicians regarding claims billed. If the ZPIC identifies inaccuracies in a medical company’s billing, the critical question for criminal referral is whether those inaccuracies were the result of billing mistakes or whether they were caused by conscious fraud. If the ZPIC auditors determine that fraud occurred, they will likely refer the matter for civil or criminal investigation.

An important first step to preventing a criminal referral is retaining experienced healthcare fraud defense lawyers that can manage communications with the ZPIC. Counsel also often recommends and may assist you in performing your own analysis of the records requested. This may allow you and your counsel to determine important information regarding the types of procedures, codes, time periods, and patients that the ZPIC is investigating. Understanding the focus of the ZPIC audit can help you and your counsel assess the scope and magnitude of the problem and explain to the auditors that any errors were unintentional. It is important to start this process as quickly as possible so that it can be completed before the ZPIC makes a decision to refer a case for prosecution. Your first priority must be to avoid criminal indictment, and your counsel will have a much easier time accomplishing that goal at the ZPIC stage rather than after the ZPIC refers a matter.

What Happens When the U.S. Attorney’s Office Gets Involved?

ZPICs frequently refer matters to the U.S. Attorney’s Office for civil or criminal investigation and enforcement. If your case is referred, the FBI or other government investigators may investigate your business. These investigators have access to much more aggressive tactics: They may raid your business, confiscating medical and billing records, computers and other related evidence. They may also freeze your private and business bank accounts. These actions could interrupt your company’s ability to do business.

Investigators may attempt to interview you or your employees. If you are confronted by investigators, it is important for you to remember that you are not required to speak with government investigators and it is generally not in your best interest to do so, even if you believe you have done nothing wrong. Investigators often have years of experience eliciting damaging admissions, and they may be more familiar with your billing practices than you are. You should always rely on your legal counsel or healthcare fraud attorney to manage communications with the government.

What Are the Penalties for Medicare Fraud?

Criminal penalties for Medicare fraud are serious and can result in incarceration of:

• Up to 10 years for each count of Medicare fraud;
• Up to 20 years for each count if the fraud resulted in serious bodily injury; or
• Up to life in prison if the fraud resulted in the patient’s death.

These penalties are in addition to restitution, criminal fines, and program exclusion.

We Can Help You

• Nick Oberheiden has successfully represented healthcare executives, business owners, public officials, physicians, and lawyers in healthcare prosecutions across the United States. Dr. Oberheiden is the managing principal of Oberheiden, P.C. and he assists clients in Dallas, Garland, Mesquite, Richardson, McKinney and surrounding communities in federal healthcare investigations.

• With a profound understanding of the law and superb litigation skills, Attorney Lynette Byrd consistently finds success for her clients. While Attorney Byrd is a former Assistant United States Attorney, she now focuses her practice on criminal and civil litigation, Medicare and insurance audits, and general advice and counseling for those with questions pertaining to healthcare law.

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.

Nick Oberheiden

Dr. Nick Oberheiden has successfully represented healthcare executives and physicians – as well as businesses in the areas of toxicology, pharmacy, home health and hospice centers, DME, hospitals, surgery centers, neuro-monitoring, and blood and DNA testing centers – in healthcare compliance and defense.