Recoupment and Payor Appeals — ZPIC and Express Script Audits
Almost every company that works with Medicare and Medicaid will at some point face a ZPIC audit that is performed by a CMS contractor such as Express Scripts, Qlarant or Cotiviti. These audits are investigations into fraud, waste and abuse.
These investigations focus on fraud, waste, and abuse within the company pertaining to health care services and related activities. These investigations are not random; many audits are instigated based on a suspicion that fraud has occurred, with the intent of identifying and proving those suspicions. The goal is to separate fraud from error. When a provider receives an audit notification, they need experienced legal counsel to help them successfully navigate the process while minimizing impact on the organization.