m-spiveyWASHINGTON, D.C. – Workload data used by the Centers for Medicare & Medicaid Services (CMS) to oversee its Zone Program Integrity Contractors (ZPICs) is not uniform and at times inaccurate, factors creating data access issues affecting the contractors’ ability to perform oversight activities, according to a report released this month by the U.S. Department of Health and Human Services (HHS) Office of Inspector General.


Authored by HHS Inspector General Daniel R. Levinson, the 44-page report was the first of its kind examining ZPIC activity, but data issues precluded the possibility of even performing a conclusive assessment, Levinson wrote. Levinson’s office has identified oversight of CMS programs and benefit integrity contractors as a “top management challenge” for HHS, the report noted, with past reports also identifying vulnerabilities in contractors’ efforts to combat fraud and abuse.


CMS remains in the process of replacing Program Safeguard Contractors (PSC) with ZPICs, which will perform Parts A and B program integrity work in seven newly established geographical zones. The first two ZPIC contracts were awarded in September 2008, with both contractors launching operations in February 2009; as of September of this year CMS had awarded the remaining five contracts and five of the seven ZPICs were operational.


Noting that the aforementioned data issues also “present a serious obstacle to CMS in effectively overseeing ZPIC operations,” the report emphasized the importance of correcting them. Specifically, the report included four recommendations, suggesting that CMS:


1) Clarify the workload definitions in CMS ARTS to ensure that ZPIC workload statistics are accurate and that ZPICs report data uniformly;

2) Improve oversight of contractors by performing a review of data in CMS ARTS for each ZPIC and across all ZPICs to detect anomalies in workload reporting;

3) Utilize and report ZPIC workload statistics in ZPIC evaluations; and

4) Ensure that ZPICs have access to all data necessary to carry out their activities.


CMS Administrator Donald Berwick issued a four-page list of comments dated Sept. 30 to Levinson regarding a rough draft of the report, and the input was incorporated into Levinson’s final draft. In referencing that input, the report noted that CMS believes that it already has complied with the first recommendation, adding that “there were some early misunderstandings, which have since been clarified.”


CMS concurred with the first part of the second recommendation (to perform a timely review of data in CMS ARTS for each ZPIC), but did not concur with the second part (to perform a timely review of data across ZPICs), the report indicated. CMS stated that “anomalies cannot be detected across ZPICs because of the differences in fraud landscapes between the ZPICs,” the report read, noting that HHS officials “disagree, and note that we detected anomalies in reporting across ZPICs, including differences in the way the ZPICs were reporting their numbers of new investigations.”  CMS also partially concurred with the third recommendation, noting that it “will consider including workload statistics for future evaluations, if appropriate,” with the agency adding that it would “welcome the opportunity to meet with OIG to discuss any workload statistics OIG believes would relate directly to ZPICs’ performance.”


Finally, CMS concurred with the fourth recommendation fully, noting that the currently awarded ZPIC Statements of Work require ZPICs to have access to daily downloads of shared system claims data. Additionally, CMS stated that it believes an effective workaround was developed for every data access problem identified in the report.


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Mark Spivey is a correspondent for the RACmonitor.com and ICD10monitor.com websites.


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