(January 26, 2010):  Pursuant to the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA), CMS was required to use competitive measures to replace the current Medicare Fiscal Intermediaries (Part A) and Carriers (Part B) contractors with Medicare Administrative Contractors (MACs).  After setting up the new MAC regions, CMS created new entities, called Zone Program Integrity Contractors (ZPICs). Intended to consolidate existing program integrity efforts, over the last year ZPICs have been taking over PSC audit and enforcement activities around the country.

Statements of Work in ZPIC contracts are similar to those covering PSCs.  In fact, Chapter 4 of CMS’s “Medicare Program Integrity Manual” reflects that the processes and procedures used by ZPICs when handling program integrity functions are essentially the same as those used by PSCs around the country.  Seven ZPIC zones have been identified.  The zones include the following states and / or territories:

• Zone 1 – CA, NV, American Samoa, Guam, HI and the Mariana Islands.
• Zone 2 – AK, WA, OR, MT, ID, WY, UT, AZ, ND, SD, NE, KS, IA, MO.
• Zone 3 – MN, WI, IL, IN, MI, OH and KY.
• Zone 4 – CO, NM, OK, TX.
• Zone 5 – AL, AR, GA, LA, MS, NC, SC, TN, VA and WV.
• Zone 6 – PA, NY, MD, DC, DE and ME, MA, NJ, CT, RI, NH and VT.
• Zone 7 – FL, PR and VI.

Upon receiving a request for records by a ZPIC:

• Take care before conducting an internal review of the claims requested.  While an internal analysis can be invaluable, you want to avoid creating a non-privileged paper trail of identified problems.  Remember, both ZPICs and RACs may make a referral to law enforcement if their assessment indicates that problems may be more than a mere overpayment.
• Review past claims audits and evaluations to determine whether these claims have been previously evaluated.
• Note the claims denied and calculate when appeals must be filed.  Review the reasons given for each denial.
• Has the contractor correctly cited Medicare policy?  Do not automatically assume the contractor’s arguments are meritorious.
• Appeals must be filed in a timely fashion.  Moreover, all supporting documentation and arguments must be submitted to the QIC

Should you have any questions regarding these issues, don’t hesitate to contact us.  For a complementary consultation, you may call Robert W. Liles or one of our other attorneys at 1 (800) 475-1906.