Report details failures of fraud efforts

Monday, November 14, 2011

WASHINGTON – ZPICs are wreaking havoc on HME providers, yet CMS doesn’t have a good grasp on whether their audits are even effective, according to an Office of Inspector General (OIG) report released this week.

A big reason why: The workload data that CMS uses to oversee the ZPICs isn’t accurate or uniform, a systematic problem that the OIG first reported on 10 years ago in a review of Medicare Part A fraud units. For example, the ZPICs count and report their new investigations differently in their workload statistics in the agency’s reporting system, the CMS Analysis, Reporting and Tracking System (CMS ARTS).

“This lack of uniformity could be the reason that one ZPIC reported seven times more investigations originating from external sources (e.g. complaints) than the other,” the OIG stated.

The OIG limited its study to the ZPICs in Zones 4 and 7 because these were the only contractors that had completed a full contract year at the time. Currently, CMS has ZPICs up and running in five of seven zones.

Due to the lack of accuracy and uniformity, CMS’s performance evaluations of the ZPICs contain few workload statistics, the OIG states.

“Neither ZPIC evaluation contained the amount of overpayments referred or the number of investigations or cases initiated as a result of proactive methods,” the office stated.

The OIG also found that lack of access to data affects the ability of the ZPICs to identify potential fraud and abuse, respond to requests for information, and track overpayment collections. One ZPIC reported it had difficulty obtaining data from the previous PSC and it had to purchase claims data on its own from another CMS contractor.

The OIG recommended that CMS take the following steps:

•    Clarify 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.

•    Utilize 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.

To read the OIG’s report, go to