Which of the following best describes actions included in Zone Program Integrity Contractor (ZPIC) and Unified Program Integrity Contractor (UPIC) investigations?

• A. Investigation, interviews
• B. Investigation, interviews, medical reviews, data analysis, administrative actions, and refer case to law enforcement
• C. Auditing and billing adjustments only
• D. Medical reviews and data analysis only

Answer: (B)

The actions in ZPIC and UPIC investigations are broad and hands-on, reflecting how program integrity bodies uncover and address fraud and improper payments. Investigators don’t stop at collecting data; they actively gather evidence through investigations and interviews with providers, staff, and others involved. They also perform medical reviews to assess whether care was medically necessary and appropriate, and they analyze data to spot billing patterns, anomalies, and potential upcoding or unnecessary services. When issues are found, they take administrative actions to recover funds, suspend or sanction providers, or refer cases for further action. If the evidence points to fraud, cases are referred to law enforcement for possible criminal prosecution. This combination of investigation, interviews, medical review, data analysis, administrative action, and law enforcement referral best captures the full scope of ZPIC/UPIC activities. Options that include only auditing or only subsets of these activities don’t encompass the complete range of actions involved.