HHS OIG: ZPICs Hindering Oversight

Report says Anti-Fraud Contractors used bad data to report workloads while being paid $22+ Billion.

Zone Program Integrity Contractors have received billions in taxpayer money, but have yet to accurately report their workloads, according to “Zone Program Integrity Contractors’ Data Issues Hinder Effective Oversight,” a new report from the HHS Office of Inspector General.

The report noted that while the Zone 4 ZPIC received $11.4 million and the Zone 7 ZPIC received $10.8 million to conduct activities under their benefit integrity task orders for the first contract year (Sept. 30, 2008, through Oct. 31, 2009), it was not reporting accurate data on its workload, and the data was so inaccurate and non-uniform that it prevented a full assessment of the situation.

Key findings from the HS OIG’s report:

  • Workload data used by CMS to oversee ZPICs were not accurate or uniform. There were inaccuracies and a lack of uniformity in ZPIC data as a result of system issues in CMS ARTS, ZPIC reporting errors, ZPICs’ interpretations of workload definitions, and inconsistencies in requests for information reports.
  • The inaccuracy and non-uniformity of ZPICs’ data prevented a conclusive assessment of ZPICs’ program integrity activities. One of our objectives was to describe the extent of ZPICs’ program integrity activities during their first year of operation. However, the inaccuracies and lack of uniformity in the ZPICs’ data prevented us from making a conclusive assessment of their activities.
  • CMS’s performance evaluations of ZPICs contained few workload statistics. Neither ZPIC evaluation contained the amount of overpayments referred or the number of investigations or cases initiated as a result of proactive methods. The performance evaluations provided limited information on requests for information.
  • Data access issues affected ZPICs’ ability to perform program integrity activities. ZPICs reported that data access issues affected their ability to identify potential fraud and abuse, respond to requests for information, and track overpayment collections.

“The inaccuracies and lack of uniformity we identified in ZPICs’ data prevented us from making a conclusive assessment of their program integrity activities; however, the issues we identified present a serious obstacle to CMS in effectively overseeing ZPIC operations,” the report reads. “It is important that these issues be corrected so that CMS can analyze ZPICs’ effectiveness in detecting and deterring fraud.”

To correct those problems, the HHS OIG suggested the following:

  • CMS should clarify the definitions of the workload statistic fields in CMS ARTS and discuss the definitions with the ZPICs to ensure uniformity of reporting across ZPICs.
  • Improve oversight of ZPICs by performing a timely review of data in the CMS Analysis Reporting and Tracking System (CMS ARTS) for each ZPIC and across ZPICs to detect any anomalies in workload reporting.
  • Once CMS has ensured that ZPICs’ workload statistics are being accurately and uniformly reported, CMS should utilize and report these statistics in ZPICs’ performance evaluations.
  • CMS should Ensure that ZPICs have access to all data necessary to effectively carry out their program integrity activities.


About the Author

David Kopf is the Publisher and Executive Editor of HME Business and DME Pharmacy magazines. Follow him on Twitter at @postacutenews.

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