Jackson Davis HealthCare
Medicare Audit Defense,
Medicare Appeals & ZPIC Shadow Audits
Contact us at (303) 586-5003
The Healthcare Provider's #1 Medicare Audit Defense & Medicare Appeals Team
ZPIC Audit Defense - ZPIC Appeals - Medicare Shadow Audits
ZPIC Audit Outcomes, CMS Extrapolation & ZPIC Appeals
ZPIC auditors refer all identified overpayments to the Medicare affiliated contractor (typically a MAC), who subsequently sends the provider a demand letter for recoupment of the perceived overpayment. In any case involving an overpayment, even where there is a strong likelihood of Medicare fraud, the MAC will typically request recovery of the overpayment.
Under most circumstances, ZPIC audit contractors may use statistical sampling to calculate and project (i.e., extrapolate) the amount of overpayment(s) made on claims. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), mandates that before using extrapolation to determine overpayments, there must be a determination of sustained or high level of payment error, or documentation that educational intervention has failed to correct the payment error.
A sustained or high level of payment error may be determined to exist through a variety of means is not subject to administrative or judicial review. Examples include: error rate determinations by ZPIC audits / MAC audits, probe samples, data analysis, provider/supplier history, information from law enforcement investigations, allegations of wrongdoing by current or former employees of a provider and audits or evaluations conducted by the OIG.
If the provider elects to appeal a claim reviewed by a ZPIC, then the ZPIC forwards its records on the case to the CMS affiliated contractor (typically a MAC) so that it can handle the Medicare appeal. ZPICs are required to have a medical specialist involved in denials that are not based on the application of clearly articulated policy with clearly articulated rationale.