Medicare Audit & Appeals

What Medicare Providers Need to Know About a Medicare Audit – Including UPIC/ZPIC Audit, Medicare Administrative Contractor and RAC Audits and Appeals

Nick Oberheiden: Your Medicare Audits Attorney

Oberheiden, P.C. – Medicare Audit Defense Lawyers
Former Medicare Prosecutors & Defense Counsel

Medicare Audit Attorney Hotline: 888-680-1745

Oberheiden, P.C. advises clients from across the country with UPIC / ZPIC audits, OESSA forms, and hospice and home health certifications. Our team of former federal healthcare prosecutors, many of which previously held positions involving oversight of medicare audits and related issues, offer clients a wealth of government and private practice experience when it comes to avoiding and defending civil and criminal healthcare investigations, and ZPIC audits in particular.

Purpose of Medicare Audits

The primary purpose of a Medicare Audit, as opposed to a random inspective audit, is to identify fraud. If a provider is selected to undergo a UPIC/ZPIC/RAC Audit (Recovery Audit Contractor) /MAC /Certified Error Rate Testing (CERT) Audit, or similar audit, it is either because it is already the subject of a fraud investigation, or ZPIC is seeking to gather more information to determine whether such an investigation should be opened, examining improper payments or billing errors, but also looking at medical necessity. Therefore, providers should recognize that a ZPIC Audit is never random and should practice utmost vigilance in promptly and effectively responding to documentation requests from ZPIC.

Almost all providers are susceptible to the intrusive demands of a ZPIC Audit. This is because ZPIC auditors are responsible for investigating all Medicare-related fraud claims involving Parts A and B (hospital, skilled nursing, home health, provider and durable medical equipment claims), Part C (Medicare Advantage health plans), Part D (prescription drug plans) and coordination of Medicare-Medicaid services. ZPIC has assigned an auditing group for each of seven different regions which include all 50 states, Puerto Rico, American Samoa, the U.S. Virgin Islands, Guam, and the Mariana Islands.

Few Limitations Placed on Medicare Auditors

Medicare auditors have far fewer limitations on the kind of information they can obtain and the means they can implement to obtain it than any other audit that is performed by CMS (Center for Medicare and Medicaid Services). When Medicare has enough reason to suspect fraud to institute a ZPIC/RAC Audit, the rules and regulations give it all the tools it needs in order to confirm the suspicion and conduct audits. It is important that while maintaining an utmost degree of cooperation, providers seek guidance from legal counsel about their rights against overly broad or impractical government requests. Nonetheless, if you treat Medicare patients, you and other providers of Medicare and Medicaid services need to know some of the explicit allowances granted to ZPIC auditors in order to avoid fruitless objections that can make the audit process more lengthy, costly, and caustic than it needs to be.

Put our highly experienced team on your side

Dr. Nick Oberheiden
Dr. Nick Oberheiden



Lynette S. Byrd
Lynette S. Byrd

Former Assistant U.S. Attorney


Ellen Comley
Ellen Comley

Senior Counsel


Roger Bach
Roger Bach

Former Special Agent (OIG)

Steven Taylor
Steven Taylor

Healthcare Compliance Consultant

Susan Sage
Susan Sage

Healthcare Auditor

First, providers must know that there is no look-back period on ZPIC Audits. The rules and regulations allow the OIG to request documentation from any prior coding by the provider, regardless of changes in business practices or personnel since the original code was billed. Second, ZPIC auditors have no limit on document requests. It is in the provider’s best interest, therefore, to make documentation as well prepared and as easily accessible as possible. Doing so can avoid significant costs and delays throughout the course of the ZPIC Audit. Third, ZPIC permits auditors to collect information on-site from various people and departments at the provider’s place of business. The auditors may visit the provider’s site without notice and may interview the provider’s employees and beneficiaries. Though this may seem unreasonably intrusive to many providers, it is important that providers comply with such requests. Fourth, ZPIC auditors use complicated data analysis methods that are difficult to assess for accuracy. For example, auditors often use probe sampling, statistical sampling & extrapolation to obtain a statistically valid random sample. In order to ensure that these methods of analyses have been instituted accurately and fairly, providers should consult legal counsel that has substantial experience in dealing with such investigations. Finally, and perhaps most importantly, providers must know that ZPIC auditors have the right to withhold payments from federally-funded programs. For providers that rely heavily on federal payers, this can be the most detrimental aspect of a ZPIC Audit. Withholding of payment is often an area where negotiations can be of greatest benefit to the provider.

Authority and Reimbursement of Auditors

Lynette Byrd
Attorney Lynette S. Byrd
Healthcare Team Lead
Former Federal Prosecutor

It is important for providers to know what authority auditors have during and after a ZPIC Audit and how they are reimbursed. Understanding the motivations and capabilities of auditors, and how those two factors interact, will help a provider better understand how to be cooperative while also ensuring a fair audit.

As stated above, auditors can withhold payments of bills submitted by providers to Medicare. The Medicare Program Integrity Manual states that a payment suspension may be used when there is: (1) reliable information that an overpayment exists, but the amount of the overpayment is not yet determined; (2) reliable information that the payments to be made may not be correct; and (3) reliable information that the provider fails to furnish records and other essential information necessary to determine the amounts due to the provider. The manual notes that in cases of suspected fraud, a payment suspension may be used when there is a credible allegation of fraud. Therefore, ZPIC auditors have strong discretion in determining whether to withhold payment. Providers must know this and be prepared to account for this reduction in revenue.

ZPIC auditors may seek recoupment for payment errors from the provider even if the investigation does not lead to a case if the auditor determines that the provider was overpaid on any particular bill or bills and will correct improper payments. Recoupment may be ZPIC’s strongest tool short of referral to the DOJ or OIG for further investigation or prosecution. If the auditor demands recoupment, it is critically important, from both a legal and business standpoint, that each bill is reviewed in depth. Demands for recoupment can be more extensive than necessary, depending on how the recoupment amount is calculated. Reviewing each bill on which recoupment is demanded is critical in ensuring that the provider is not paying more than necessary.

Understanding how auditors are reimbursed can help providers both keep them accountable and help them conduct the audit as efficiently as possible. Although ZPIC auditors are not paid on contingency fees, performance bonuses do exist. Providers must understand that ZPIC auditors, unlike in other randomized audits, begin the performance of their job with a suspicion of fraud, and are searching to find evidence to back up their suspicion, conducting probe audits. It is important that in that effort, providers are forthright and cooperative, but also vigilant in keeping a check on the auditor. This can be done by maintaining a chronology of all communications with the auditor. With this understanding, and an understanding of the other factors mentioned above, a provider will be well-informed and prepared for any demands of a ZPIC Audit.

Our Experience with Medicare Audits

Thousands of audit requests are made every year, in one of their varying forms, such as MAC, UPIC, Recovery Audit Contractor (RAC audits) and so forth. Oberheiden, P.C. has extensive experience advising and counseling clients during the ZPIC Audit process. The Firm also has an impeccable track record when it comes to achieving favorable outcomes in ZPIC Audits and avoiding referral to the Department of Justice for further investigation or prosecution, including through the appeals process when necessary. The experience of our attorneys, many of which served the Department of Justice until recently as supervising healthcare fraud prosecutors, covers all aspects of healthcare compliance as well as effective defense strategies. Because we know what type of information the government is looking for, we can prepare our clients to avoid common mistakes through these internal audits.

Medicare Audit Attorney

Why Do Clients Trust Oberheiden, P.C.?

It is troubling to learn that you have become the target of a federal investigation, for obvious reasons. Clients come to us after carefully considering their options, especially with respect to which law firm they will retain to represent them. There are several reasons why clients consistently choose us to represent them.

1. Federal Experience

Federal law works very differently than the local laws of the various states. Even federal law itself differs somewhat by jurisdiction. Unlike most attorneys, our attorneys are highly experienced in practicing federal law. This expertise allows us to help you defeat a federal investigation – or provide regulatory compliance guidance – in order to head off an investigation before it ever begins.

2. Experience on Both Sides of the Aisle

Our notable federal experience greatly benefits our clients every single day. It wouldn’t be complete, however, without a clear understanding of what is going on inside the minds of the opposing party. We understand the federal government’s strategy and mindset because several of our attorneys joined us after successfully serving as federal prosecutors for years.

3. Concrete Results

When you become the target of a federal investigation, the stakes are potentially immense – bankruptcy, poverty, the loss of a professional license, or perhaps even incarceration. Years of experience and superior legal strategy don’t matter at all unless they lead to a favorable ultimate outcome of your case in a timely and cost-effective manner. Our track record speaks clearly – in fact, many of our clients have been elated to find that their investigation has been concluded with no civil or criminal liability.

4. Teamwork

If the federal government prioritizes its investigation against you, it will take advantage of its nearly unlimited resources to assign a team of investigators, federal agents, and prosecutors to your case. At Oberheiden, P.C., we know that two can play at that game, and we will respond by assigning your case to a team of attorneys who have been working cohesively together for years.

5. Our Commitment

At Oberheiden, P.C., our absolute commitment to our client’s cause is the primary virtue that makes everything else work. We would not be fit to handle your case if we didn’t treat it with just as much urgency as we would treat an investigation where we were the targets ourselves.

Our Medicare Audit Attorneys

Our team has successfully defended business owners, healthcare executives, and medical professionals through ZPIC audits and other cases involving the Federal Bureau of Investigation (FBI), the Medicaid Fraud Control Unit (MFCU), the Office of Inspector General (OIG), the Department of Justice (DOJ), the Department of Defense (DOD), the Internal Revenue Service (IRS), and other law enforcement agencies.

Call us today (or fill out our contact form) and speak to one of our experienced ZPIC Audit attorneys directly. We are available to discuss your situation in a free and confidential call, including on weekends.

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