GAO: Medicare fraud watchdogs need better oversight


The Centers for Medicare & Medicaid Services can do a better job monitoring the work of zone program integrity contractors (ZPIC) responsible for finding and investigating potential Medicare fraud, concludes a report from the Government Accountability Office.

The GAO credited CMS for implementing some best oversight practices, such as evaluating ZPIC processes and results, including the number of overpayments referred for collection, reported McKnight's Long-Term Care News.

But overall, GAO recommended oversight improvement, urging CMS to "collect and evaluate the timeliness of ZPICs investigative and administrative actions, and develop ZPIC performance measures that explicitly link ZPICs work to Medicare program integrity performance measures and goals," according to the GAO report summary.      

The GAO's report acknowledged the challenges of measuring the outcomes of ZPIC activities, especially without a healthcare fraud baseline to track fraud changes over time. It's also difficult to determine a causal relationship between ZPIC efforts and fraud volume.

Nevertheless, CMS could link ZPIC use of the electronic fraud prevention system to the number of administrative actions opened against suspect providers, the report noted.      

The GAO also found CMS paid ZPICs about $108 million last year, which contractors largely spent on anti-fraud fieldwork, including beneficiary interviews, on-site audits and more than 200,000 claims reviews using data analytics. The return on investment included Medicare saving $250 million, law enforcement accepting 130 cases for possible prosecution and ZPICs revoking Medicare billing privileges for 160 aberrant providers.     

The GAO considers Medicare a high-risk fraud target due to its complexity and scope. Accordingly, the Office of Inspector General's updated strategic plan describes a multi-faceted approach to prevent, detect and deter fraud in government programs, including Medicare.

For more:
- read the GAO report summary and full report (.pdf)
- see the McKnight's article

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