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OIG Releases Report Highlighting ZPIC Oversight Issues

Recently, the Department of Health and Human Service’s Office of Inspector General released a report which found that the workload data used by the Centers for Medicare and Medicaid Services (CMS) to oversee its Zone Program Integrity Contractors (ZPICs) were inaccurate and lacked uniformity.

The study was conducted by collecting and reviewing ZPICs’ workload data related to investigations, case referrals, requests for information, and administrative actions between February 1, 2009 and October 31, 2009. The OIG only reviewed the information of the ZPICs for Zones 4 and 7 because they were the only ZPICs who had completed a full contract year at the time the study was conducted.

According to the OIG, one of the study’s major objectives was to describe the extent of ZPICs’ program integrity activities during the first year of operation. However, this objective went unachieved due to the inaccuracies and lack of uniformity which stemmed from system issues in CMS’s Analysis, Reporting, and Tracking System (CMS ARTS), ZPIC reporting errors, ZPICs’ interpretations of workload definitions, and inconsistencies in requests for information reports. The OIG also identified a number of issues inhibiting CMS from successfully overseeing ZPIC activities. The OIG has stressed that it is important that these issues are corrected so that CMS can properly analyze the ZPICs effectiveness and compare the ZPICs to their predecessors (Program Safeguard Contractors). The OIG has made a number of recommendations to CMS, which include that CMS:

  • Clarify the workload definition 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;
  • Utilize and report ZPIC workload statistics in ZPIC evaluations; and
  • Ensure that ZPICs have access to all data necessary to carry out their program integrity activities.

CMS has claimed that it has already complied with the OIG’s first recommendation. Also, CMS concurred with the first part of the second recommendation, but it failed to concur with the second part of the second recommendation and stated that “anomalies cannot be detected across ZPICs because of the difference in fraud landscapes between ZPICs.” In addition, CMS partially concurred with the OIG’s third recommendation and fully concurred with the fourth.

If you have any questions relating to ZPIC audits, or need assistance in implementing an effective compliance program to protect against future ZPIC audits, please contact a Wachler & Associates attorney at 248-544-0888.