The ZPIC, which is similar to RAC, focuses on billing trends and patterns of providers who bill higher for Medicare services than most of the other providers in an area.

They are set up to “find and prevent waste, fraud and abuse in Medicare,” according to industry reports.

What’s the difference?
ZPIC doesn’t work on a contingency basis, but instead is paid by CMS, and likely will have to meet CMS standards.

It also works to identify suspected fraud and act on it immediately, which could lead to review and possible suspension of payments, or even denial with action to recoup overpayments.

And all cases of potential fraud are sent to the Office of Inspector General, where further action could be taken.

Building a ZPIC
Several methods are used to deal with potential fraud before it can happen, and to address any possibilities after the fact.

The ZPIC IT Systems uses claims and other data to establish a data analysis platform. That comprehension of data should encompass the beneficiary’s claim history independent of where the claim was processed, with the main source being the CMS National Claims History.

When fraud is suspected, RAC must report it, but denial and subsequent provider repayment won’t necessarily stop a ZPIC investigation of allegations of fraud from overpayment.

Upon review
A ZPIC can change the code or deny a claim, in part or in its entirety, though a physician doesn’t have to review that claim for it to be denied.

So, it’s important to evaluate every ZPIC denial and appeal any possibly inappropriate denials of claims if needed, because your cost can be more than loss of revenue.