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ZPIC audits on the rise: Tips for pharmaceutical companies

Zone program integrity contract (ZPIC) audits are on the rise. These audits can result in evidence given to the Department of Health and Human Services (HHS) Office of Inspector General (OIG) and potentially result in criminal charges.

ZPICs were created by the Centers for Medicare and Medicaid Services (CMS) to find instances of health care fraud and hold alleged offenders accountable for violations. Some reports claim ZPIC investigations are more aggressive and invasive compared to other types CMS inspections.

As a result, proactive measures may be wise.

How can pharmaceutical companies prepare for a ZPIC audit? It can help to know the general process. ZPIC audits can include unannounced site visits, repeated requests for documentation, interviews with staff and management and a review of billing. Those that find themselves the subject of a ZPIC investigation can take steps to protect their interests. These steps include:

  • Get organized. It is important to have documentation often requested by auditors ready. This often includes documentation needed to support payment requests from insurance providers, Medicare as well as private insurance companies.
  • Review compliance. Ideally, the company should already have a compliance program in place to review billing and coding practices. Review the program and update as needed. If the company does not yet have one, put one in place.

It is often wise for pharmaceutical companies to conduct regular internal audits to help better ensure the facility is in compliance with applicable regulations. These audits can result in the discoveries that require a resolution. Making required changes prior to an audit may come at an expense, but it is likely much less costly than a negative audit by the ZPIC that could lead to further investigation from the OIG.