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Healthcare Providers

Compliance in Healthcare: Understanding Zone Program Integrity Contractor Investigations and Audits  

The Centers for Medicare and Medicaid Services (CMS) have a multitude of resources to detect and protect against fraud and abuse in claims. Particularly, CMS has at least six types of contractors that provide different roles in the prevention, detection, and reporting of fraud and abuse in healthcare. This list includes Recovery Auditors, which serve to reduce fraud and abuse by detecting and collecting overpayments from entities and Comprehensive Error Rate Testing (CERT) Contractors, which determine rates of improper payments by reviewing claims under Medicare Fee-For-Service (FFS). Another auditor that providers should be particularly mindful of are the Zone Program Integrity Contractors (ZPICs). This article is an overview ZPICS, its role in Medicare, and outlines the steps providers should take when faced with an audit by ZPICs.

Trump Administration Creates New Division of Health and Human Services

The Trump administration has established a new division within the Department of Health and Human Services (HHS) called the Conscience and Religious Freedom Division. The stated purpose of this office is to “restore federal enforcement of our nation’s laws that protect the fundamental and unalienable rights of conscience and religious freedom.”

One day after the creation of this division, HHS proposed a new rule, providing further protections to healthcare workers who object to providing certain types of care to patients—including elective sterilization, gender reassignment surgery, or emergency contraception—based on their personal religious beliefs. Additionally, the Trump administration issued a new directive, reversing an Obama administration directive which prohibited states from refusing to send federal funds to qualified providers. This new division, new rule, and new directive serve to ensure the already-existing rights of physicians, nurses, and healthcare staff at the expense of their patients.