OIG: Conflict of interest among potential ZPICs

Wednesday, July 11, 2012

WASHINGTON – Companies that seek ZPIC contracts from CMS often have conflicts of interest that could compromise the integrity of the program, according to a new report from the Office of Inspector General (OIG).

The OIG reviewed conflict-of-interest information for 18 such companies, called offerors, and 85 subcontractors and found that, while many had business and contractual relationships with CMS and other offerors, they didn't consider them conflicts of interest. They reported having relationships with CMS or contractors of CMS that provide Medicare Parts C and D plans, claims processing, program integrity, and/or quality improvement services.

Currently, CMS requires that offerors disclose information about possible conflicts, but it does not have a formal policy for reviewing that information, according to the OIG.

As a result, the OIG recommends, among other things, that CMS:

• provide clearer guidance in RFPs regarding which business and contractual relationships should be identified as actual conflicts and which should be identified as possible conflicts;

• state whether offerors and subcontractors need to report income amounts, periods of performance, and types of work performed for their contracts with CMS and income amounts generated from key personnel’s other employment; and

• create a standardized format for reporting information in the organizational conflict of interest certificate and require its use by offerors and subcontractors.

To read the OIG’s report: http://t.co/dKpmULUk.



We had this release yesterday morning when the OIG published the report.  Here is the scenario. Insurance company A owns the subsidiary auditor B.  Insurance Company A has a medicare intermediary contract to process claims in a geographic location.  Keep in mind this scenario concerns the entire medicare system NOT just HME and NOT just ZPIC's.  Subsidiary auditor B has a medicare contract to audit medicare Providers.  Now Insurance Company A gets paid on a claims processed and paid volume.  Subsidiary B gets paid to seek out the "Bad Guys" "Fraudulent Claims Mills".  Subsidiary A is getting paid on the volume of claims processed Fraudulent or NOT.  Do you see where this is going?

For ALL the "Fraudulent Claims Mills" shut down by the subsidiary B auditors Insurance Company A loses "MONEY"!!!!!!!!!!!!!!!!!  Now I am NOT alleging or accusing anyone of anything but these are the facts.  Now one may hide the facts by saying Subsidiary Auditor B doesn't audit the geographic area where insurance Company A has a contract to process claims but I think if they were ALL smart enough to create this scenario well again you all draw your own conclusions.  Remember the GAO reported that these auditors seeking out The "Bad Guys" wasn't that good only a few months ago.

What I think is both Funny & Sad.  These are supposed to be the "Gatekeepers"!  White as snow?? 

Now I ask "who is the "Bad Guy"??

My legal team has some really great surprises for The Federal Judges when we hopefully get a Court date.