The RAC will request medical records
from the provider to determine whether
overpayment(s) and/or underpayment(s)
have occurred. When medical records
are submitted, the process is called a
Complex Review. In these cases, the RAC
has determined there is a high probability
(but not certainty) that the claim contains
an overpayment. paid on a contingency fee basis. Instead
they compete for one of the few ZPIC
contracts that are awarded periodically.
They are also eligible to receive
performance bonuses. ZPIC auditors are
not limited to only auditing claims paid in
recent years or on the number of claims
that may be audited. There is also no limit
on the amount of documents a ZPIC may
request.
ZONE PROGRAM INTEGRITY
CONTRACTORS (ZPIC/UPIC) SUPPLEMENTAL MEDICAL REVIEW
CONTRACTOR (SMRC)
ZPICs detect, deter, and prevent fraud,
waste, and abuse in the Medicare
program. ZPICs, unlike RACs, are not The SMRC evaluates medical records
and related documents to determine
whether Medicare claims were billed
RECOVERY AUDITORS (RAC)
Current Pedorthics | March/April 2018
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