Practice Brief
ZPICs
Effective January 26, 2009, benefit integrity work transitioned
from Program Safeguard Contractors and the Medicare Prescription Drug Integrity Contractors into Zone Program Integrity Contractors, which will be located in seven zones. The scope
of work for ZPICs is similar to the previous scope of work carried out by the earlier contractors. ZPIC auditors perform a wide
range of medical review, data analysis, and evidence-based policy auditing activities designed to find fraud, abuse, and waste
within the Medicare system.
These audits are often the most concerning for organizations
and providers because they have a tendency to use statistical
data sampling and extrapolation methods. These methods allow ZPIC auditors to recoup overpayments totaling hundreds
of thousands of dollars. ZPIC audits should not be taken lightly
and organizations should handle these types of audits with due
diligence. ¢
Notes
1. Association of Clinical Documentation Improvement Specialists. “ACDIS Advisory Board FAQ.”
2. Centers for Medicare and Medicaid Services. “Recovery
Audit Contractor (RAC) Demonstration High-Risk Medical Necessity Vulnerabilities for Inpatient Hospitals.” MLN
Matters SE 1027. November 12, 2010. https://www.cms.
gov/MLNMattersArticles/downloads/SE1027.pdf.
3. “Top Ten Health Care Compliance Risks for 2011.” January 1, 2011. www.zpicaudit.com/2011/01/top-ten-health-
care-compliance-risks-for-2011.
4. Ibid.
References
American Hospital Association. “Recovery Audit Contractor
(RAC) Program.” www.aha.org/aha/issues/RAC.
Centers for Medicare and Medicaid Services (CMS).
“Demonstration to Work toward Assuring Accurate
Medicare Payments.” Press release. March 28, 2005. www.
cms.gov.
CMS. “Final Scope of Work.” www.cms.gov/RAC/downloads/
Final.
CMS. “The Medicare Recovery Audit Contractor (RAC)
Program: An Evaluation of the 3-Year Demonstration.” June
2008. www.cms.gov/Recovery-Audit-Program/Downloads/
Appealupdatethrough63008of RACEval Rept.pdf.
CMS. “MMA—The Centers for Medicare & Medicaid Services
(CMS) Recovery Audit Contractor (RAC) Initiative.” MLN
Matters SE0469. https://www.cms.gov/MLNMattersArticles
/downloads/SE0469.pdf.
CMS. “Recovery Audit Contractor Overview.” www.cms.gov/
RAC.
Johnson, Kathy M., et al. “RAC Ready: How to Prepare for the
Recovery Audit Contractor Program.” Journal of AHIMA 80,
no. 2 (Feb. 2009): 28–31.
Wilson, Donna D. Responding to a Recovery Audit Contractor
(RAC) Evaluation. Chicago, IL: AHIMA, 2010.
Appendixes
Two appendixes are available in the online version of this prac-
tice brief, found in the AHIMA Body of Knowledge at www.ahi-
ma.org:
x Appendix A: Department of Justice Statistics for FY 2010
Activities
x Appendix B: HEAT Strike Force FY 2010 Activities
Prepared by
Dawson Ballard, CCS-P, CPC, CEMC
Cathy Brownfield, RHIA, CCS
Karen Cole, RHIT, CCS-P, RCC, CPC-H, CGCS
Kathy DeVault, RHIA, CCS, CCS-P
Sharon Easterling, MHA, RHIA
Mary Gregory, RHIT, CCS, CCS-P, CPC
Tedi Lojewski, RHIA, CCS
Pat Maccariella-Hafey, RHIA, CCS, CCS-P, CIRCC
Ginny Martin, RHIA, CCS
Kathy Myrick, RHIT, CCS
Mary Stanfill, RHIA, CCS, CCS-P
Lou Ann Wiedemann, MS, RHIA, FAHIMA, CPEHR
Donna Wilson, RHIA, CCS, CCDS
Ann Zeisset, RHIT, CCS, CCS-P
Acknowledgments
Kathy Arner, LPN, RHIT, CCS, CPC, MCS, CPMA
Judy Bielby, MBA, RHIA, CPHQ, CCS
Angela Dinh, MHA, RHIA, CHPS
Julie Dooling, RHIT
Gwen Jimenz, RHIA
Carole Liebner, RHIT, CCS
Laura Rizzo, MHA, RHIA
Joyce Shearry, RHIA, CCS
Heather Taillon, RHIA
Diana Warner, MS, RHIA, CHPS, FAHIMA
The information contained in this practice brief reflects the consensus opinion of the professionals who developed it. It has not been validated through scientific research.
