Zone4 logoTo oversee the integrity of all Medicare-related claims of providers, the Centers for Medicare & Medicaid Services (CMS) has established seven zones across the nation and hires Zone Program Integrity Contractors (ZPICs) to audit providers and suppliers to identify cases of suspected fraud in each zone.

Health Integrity serves as the Zone 4 ZPIC encompassing Texas, Colorado, New Mexico, and Oklahoma.

As the ZPIC for this region, our team plays a key role in protecting the following Zone 4 Medicare services from fraud, waste, and abuse:

  • Medicare Part A—Hospitals, Home Health, and Hospice
  • Medicare Part B—Fee-For-Service, Office Visits, X-Rays, Blood Tests, Ambulance Services, etc.
  • Durable Medical Equipment (DME)
  • Medicare Medicaid Data Match Project—This partnership between Medicare and Medicaid enhances collaboration among state Medicaid agencies, the Centers for Medicare & Medicaid Services (CMS), and law enforcement officials to identify improper billing and utilization patterns throughout Texas, Colorado, and Oklahoma.

Our work in these efforts includes the following six tasks:

  1. Performing Data Analysis and Data Mining
  2. Conducting Medical Reviews in Support of Benefit Integrity
  3. Supporting Law Enforcement and Answering Complaints
  4. Investigating Fraud and Abuse
  5. Recommending Recovery of Federal Funds through Administrative Action
  6. Referring Cases to Law Enforcement

ZPIC - Law Enforcement RFI

Federal law enforcement agencies may submit a Request for Information (RFI) to obtain Medicare claims data.  Upon receipt of an RFI from a federal agency we will provide the requested claims information and data analysis in graphs and tables.

Download Data Request Form

HIPAA Compliant Data Analysis Request [doc] (09/29/14)

CMS Fraud Prevention Training Modules for Providers

In June 2012, the Centers for Medicare & Medicaid Services (CMS) produced two fraud prevention training modules that are currently available on the Medscape website (www.medscape.org). These modules provide key information to health care practitioners and professionals on how they can assist CMS in preventing fraud and abuse, as well as highlight CMS’ efforts to fight fraud and abuse and explain how health care professionals can be part of these efforts.

Reducing Medicare and Medicaid Fraud and Abuse: Protecting Practices and Patients

How CMS Is Fighting Fraud: Major Program Integrity Initiatives

Download the following document for additional details:

CMS Fraud Training Modules for Providers [pdf]

Note: Access requires a registered Medscape account. Medscape accounts are free, and users do not have to be health care professionals to register. Registration is on the Medscape website landing page: www.medscape.com