In the never ending governmental change, here comes another.

Your friendly neighborhood Program Safeguard Contractor (PSC) has been renamed to Zone Program Integrity Contractor (ZPIC).

What’s changed?

  • The name
  • The methods (?)
  • Some zones

Here is the current ZPIC zone lineup:

ZPIC Zone States in Zone
Safeguard Services (SGS) 1 California, Hawaii, Nevada, American Samoa, Guam, the Mariana Islands
AdvanceMed 2 Washington, Oregon, Idaho, Utah, Arizona, Wyoming, Montana, North Dakota, South Dakota, Nebraska, Kansas, Iowa, Missouri, Alaska
Cahaba 3 Minnesota, Wisconsin, Illinois, Indiana, MIchigan, Ohio, Kentucky
Health Integrity 4 Colorado, New Mexico, Texas, Oklahoma
AdvanceMed 5 Arkansas, Louisiana, Mississippi, Tennessee, Alabama, Georgia, North Carolina, South Carolina, Virginia, West Virginia
Under Protest 6 Pennsylvania, New York, Delaware, Maryland, D.C., New Jersey, Massachusetts, New Hampshire, Vermont, Maine, Rhode Island, Connecticut
Safeguard Services (SGS) 7 Florida, Puerto Rico, Virgin Islands

 

According to the CMS:

The primary goal of ZPICs is to investigate instances of suspected fraud, waste, and abuse. ZPICs develop investigations early, and in a timely manner, take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid. They also identify any improper payments that are to
be recouped by the MAC. Actions that ZPICs take to detect and deter fraud, waste, and abuse in the Medicare Program include:

ZPIC Functions

  • Investigating potential fraud and abuse for CMS administrative action or referral to law
    enforcement;
  • Conducting investigations in accordance with the priorities established by CPI’s Fraud Prevention
    System;
  • Performing medical review, as appropriate;
  • Performing data analysis in coordination with CPI’s Fraud Prevention System;
  • Identifying the need for administrative actions such as payment suspensions and prepayment or auto-denial edits; and,
  • Referring cases to law enforcement for consideration and initiation of civil or criminal prosecution.

 

In performing these functions, ZPICs may, as appropriate:

  • Request medical records and documentation;
  • Conduct an interview;
  • Conduct an onsite visit;
  • Identify the need for a prepayment or auto-denial edit and refer these edits to the MAC for
    installation;
  • Withhold payments; and,
  • Refer cases to law enforcement.

Non-ZPIC Funtions

The following are some of the major functions that the ZPICs do not perform.  These function are performed by the MAC (yes the Medicare Administrative Contractor).

  • Claims processing, including paying providers/suppliers;
  • Provider outreach and education;
  • Recouping monies lost to the Trust Fund (the ZPICs identify these situations and refer them to the MACs for the recoupment);
  • Medical review not for benefit integrity purposes;
  • Complaint screening;
  • Claims appeals of ZPIC decisions;
  • Claim payment determination;
  • Claims pricing; and
  • Auditing provider cost reports.