A U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) report examining the program integrity activities of Zone Program Integrity Contractors (ZPICs) has found repeated problems among the fraud contractors it examined and system failures by the Centers for Medicare & Medicaid Services (CMS) to adequately supervise them.
According to the report, ZPICs are replacing CMS’ Program Safeguard Contractors (PSC) and will perform Medicare Parts A and B program integrity work in seven newly established geographical zones. CMS awarded the first two ZPIC contracts for Zones 4 and 7 on September 30, 2008, and both ZPICs were operational as of February 1, 2009. The OIG study was limited to these two ZPICs because they were the only ZPICs that had completed a full contract year at the time of the OIG review. The OIG collected and reviewed ZPICs workload data related to investigations, case referrals, requests for information, and administrative actions from February 1 through October 31, 2009. Additionally, the OIG reviewed ZPICs’ performance evaluations and surveyed the ZPICs to identify any barriers they encountered in performing their program integrity activities.
The report found inaccuracies and a lack of uniformity resulted from system issues in CMS’ Analysis, Reporting, and Tracking System (CMS ARTS); ZPIC reporting errors; ZPICs’ interpretations of workload definitions; and inconsistencies in requests for information reports.
OIG Recommendations
The OIG has made the following recommendations to CMS:
- Clarify the workload definitions in CMS ARTS to ensure that ZPICs workload statistics are accurate and that ZPICs report their data uniformly.
- Improve oversight of ZPICs by performing a timely review of data in CMS ARTS for each ZPIC and across ZPICs to detect any anomalies in workload reporting.
- Use and report ZPIC workload statistics in ZPIC evaluations.
- Ensure that ZPICs have access to all data necessary to effectively carry out their program integrity activities.
CMS Response
According to the report, CMS believes it has already complied with the first recommendation. CMS concurred with the first part of the second recommendation; however, it did not concur with the second part and stated that anomalies cannot be detected across ZPICs because of the differences in fraud landscapes between the ZPICs. The OIG disagrees with this statement and noted that anomalies in reporting were detected between ZPICs, including differences in the way ZPICs were reporting their numbers of new investigations. CMS partially concurred with the third recommendation and stated it will consider including workload statistics for future evaluations, if appropriate. CMS concurred with the fourth recommendation.
