ZPIC - Case Referral

Referring Fraud, Waste, or Abuse Cases to ZPIC

Any suspected fraud, waste, or abuse in Medicare Parts A, B, DME, Home Health, & Hospice for TX, OK, CO, and NM should be referred to the ZPIC. Fraud cases may involve beneficiaries, physicians or other providers, or other organizations. CMS requires referrals for fraud cases to be made within 30 days of detection. Timely referrals are necessary to take full advantage of leads in an investigation and as time progresses, important information in a case may become more difficult to track down.

What cases should be referred?

Cases meeting any of the following criteria should be referred to the ZPIC:

• Potential criminal, civil, or administrative law violations
• Allegations extend beyond one provider, involving multiple providers, multiple states, or widespread schemes
• Allegations involving known patterns of fraud
• Pattern of fraud or abuse threatening the life or well being of beneficiaries
• Scheme with large financial risk to the Medicare Program or  beneficiaries

What information should be included in a referral?

Every referral to the ZPIC should contain specifics that will allow an investigator to follow up on a case including basic identifying information and contacts as well as a description of the allegations.

If available a referral should include:

• Your name, organization, and contact information for follow up
• Summary of the Issue
• Include the basic who, what, when, where, how, and why
• Any potential legal violations
• Specific Statutes and Allegations
• List civil, criminal, and administrative code or rule violations, state and federal
• Provide detailed description of the allegations or pattern of fraud, waste, or abuse
• Incidents and Issues
• List incidents and issues related to the allegations
• Background information
• Contact information for the complainant, the perpetrator or subject of the investigation, and beneficiaries, providers, or other entities involved.
• Additional background information that may assist investigators, such as names and contact information of informants, relators, witnesses, websites, geographic locations, corporate relationships, networks.
• Perspectives of Interested Parties
• Perspective of provider, CMS, beneficiary
• Data
• Existing and potential data sources
• Graphs and trending
• Maps
• Financial impact estimates
• Recommendations in  Pursuing the Case
• Next steps, special considerations, cautions

How should the referral be transmitted?

Because specific information may include data protected by HIPAA or the Privacy Act, referrals should be transmitted by one of the following methods:

1. Call the ZPIC at (972) 383-0000 and provide the information to our complaint specialists who will key the information into a database, acknowledge and follow up on the complaint.

2. Complete and fax a Fraud Referral Form [pdf] to the ZPIC at (972) 383-0010 or mail it to:
   
   Health Integrity, LLC
   Heritage Square 1
   4835 LBJ Freeway, Suite 750
   Dallas, Texas 75244-6017
   Attn.: ZPIC

What follow up might occur?

When referring a case, please keep in mind that ZPIC investigators may be contacting you later to discuss details or obtain written documents or other information. Any information related to a potential fraud case should be retained for 10 years.

As an investigation ensues, new leads and data may suggest additional questions or actors involved in a case. Often an initial allegation may be the tip of an iceberg. Be ready to respond as a case develops.