Zone Program Integrity Contractor (ZPIC) – Zone 4 Contract Overview

The Centers for Medicare & Medicaid Services (CMS) continues its efforts to ensure the highest integrity of its programs and the healthcare security for all its beneficiaries. To help achieve these goals, CMS created new entities entitled Zone Program Integrity Contractors (ZPICs). The Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA) changed CMS’ current contracting structure by phasing out the fiscal intermediaries and carriers while phasing in the Medicare Administrative Contractors (MAC) for Medicare claims processing. As a result, seven zones have been created based on the newly established MAC jurisdictions.

CMS awarded the ZPIC contract for Zone 4 (which encompasses Colorado, New Mexico, Oklahoma, and Texas) to Health Integrity, LLC. As of February 1, 2009, Health Integrity has been performing the integrity functions for Medicare Parts A, B, Durable Medical Equipment (DME), Home Health and Hospice, as well as the Medicare Medicaid Data Match project. These efforts include 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

Through these efforts, Health Integrity:

• Develops innovative data analysis methodologies for detecting and preventing abusive use of services early
• Develops high quality fraud case referrals for law enforcement
• Identifies appropriate corrective actions

Health Integrity manages this workload from offices located in Dallas, Texas; San Antonio, Texas; Houston, Texas; Brownsville, Texas; Denver, Colorado; Oklahoma City, Oklahoma; and Albuquerque, New Mexico. Health Integrity staff include data analysts, nurse reviewers, and fraud investigators.

To contact Health Integrity, LLC call (972) 383-0000.