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Partnering with state Medicaid Program Integrity units to perform the above activities for the Medi-Medi program or.Initiating and maintaining networking and outreach activities to ensure effective interaction and exchange of information with internal components as well as outside groups.
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Referring any necessary provider / supplier and beneficiary outreach to the Provider Outreach and Education staff at the MAC.Referring cases to the OIG’s Office of Investigations (OI) for consideration of civil and criminal prosecution and/or application of administrative sanctions.Initiating appropriate administrative actions where there is reliable evidence of fraud, including, but not limited to, payment suspensions and revocations.Exploring all available sources of fraud leads in its zone, including the state Medicaid agency and the Medicaid Fraud Control Unit (MFCU).Investigating (determining the factual basis of) allegations of fraud made by beneficiaries, providers / suppliers, CMS, the Office of Inspector General (OIG), and other sources.Proactively identifying incidents of potential fraud, waste, and abuse that exist within its service area and taking appropriate action on each case.Preventing fraud by identifying program vulnerabilities.As CMS has described its role, the “ZPIC is responsible for preventing, detecting, and deterring fraud, waste and abuse in both the Medicare program and the Medicaid program through the collaboration of the Medicare-Medicaid Date Match Program (Medi-Medi).” To accomplish these responsibilities, ZPICs are tasked with:.In recent years, ZPICs have been aggressively pursuing a wide variety of enforcement actions. Additionally, experience has shown us that despite the fact that ZPICs are expected to adhere to applicable Medicare coverage guidelines, a ZPIC’s interpretation and application of these coverage requirements may greatly differ from your understanding of the same provisions. Nevertheless, common sense tells us that if ZPICs are unsuccessful at identifying alleged overpayments, the chances of a ZPIC’s government contract being renewed are likely to be diminished. Instead, ZPICs are directly compensated by CMS on a contractual basis. Notably, ZPICs have traditionally asserted that, unlike their Recovery Audit Contractor (RAC) counterparts, they are not “bounty hunters.” They base this argument on the fact that unlike RACs, ZPICs are not paid on a contingency basis. Zone 7 – SafeGuard Services : Florida, Puerto Rico and.Zone 6 – SafeGuard Services : Pennsylvania, New York, Maryland, District of Columbia, Delaware, Maine, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire and Vermont.Zone 5 – AdvanceMed (an NCI Company) : Alabama, Arkansas, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Virginia and West Virginia.Zone 4 – Health Integrity: CO, NM, OK, TX.Zone 3 – AdvanceMed (an NCI Company ) : Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin.Zone 2 – AdvanceMed (an NCI Company) : Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming.Zone 1 – SafeGuard Services : California, Hawaii, Nevada and the territories of American Samoa, Guam, the Northern Mariana Islands, Palau, the Marshall Islands and the Federal States of Micronesia.Listing of ZPICs Previously Operating Under a Contract with CMS To date, CMS has awarded all of the ZPIC contracts and is close to completing the transition over from the PSC system. When the contracts expired, CMS transferred the PSCs’ fraud detection and deterrence functions over to ZPICs around the country. Īt the time of transition, there were twelve PSCs that had been awarded umbrella contracts by CMS. Since the enactment of MMA, ZPICs have largely taken over the program integrity duties previously handled by Program Safeguard Contractors (PSCs). The Centers for Medicare and Medicaid Services (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) Īfter setting up the new MAC regions, CMS was required to create new entities, called Zone Program Integrity Contractors (ZPICs) andĬMS worked to consolidate its existing program integrity efforts. On December 8, 2003, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) was signed into law.