Mock Integrity/ZPIC Audit


The Centers for Medicare & Medicaid Services (CMS) established seven zones based on the Medicare Administrative Contractor (MAC) jurisdictions. As a result, the Zone Program Integrity Contractors (ZPICs) were created to perform program integrity functions for Medicare.

According to CMS, the primary goal of ZPICs is “to identify cases of suspected fraud, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped.”

Potential Risk to Providers:

Unfortunately for some providers, ZPIC auditors have been known to use aggressive tactics in their investigations by arriving at facilities unannounced and asking to speak to staff members in the middle of their shifts, for example.

Another tool being aggressively utilized by ZPICs is statistical sampling, in which the auditor reviews a sample of claims, representing perhaps several thousand dollars, and extrapolates that analysis into an assertion that the provider owes the Government hundreds of thousands of dollars.

Other ZPICs have put providers under a pre-payment review that prevents the facility from billing to Medicare until the ZPIC has reviewed the claims.

How can Harmony Healthcare International (HHI) help: 

HHI Integrity audits assist healthcare providers in insulating reimbursement for Medicare and Medicaid residents through an understanding of Prepayment review, Governmental investigations and Medical reviews occurring throughout the country in the SNF setting. The HHI Integrity audit illuminates exposure areas within the medical record and with therapy treatment practices placing providers at risk for repayment of monies to the Government for skilled services provided.  The HHI Integrity audit allows facilities to identify potential fraudulent claims.

The HHI Integrity audit process is an intensive detailed review of the medical record content for medical record accuracy, compliance concerns in addition to observation of clinical practices. The Integrity audit process includes medical record review, onsite education for all appropriate staff, staff interviews, an exit conference with facility leaders, in addition to a comprehensive written report.

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