Department of Health and Human Services 

 
 
 
  OFFICE OF 

 
  INSPECTOR GENERAL 

 
 
 
 
 
M B I
EDICARE  ENEFIT  NTEGRITY 
C  A  
ONTRACTORS   CTIVITIES IN 
2012 2013 
 AND 
 
A D C  
  ATA  OMPENDIUM 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
   
 
Office of Inspector General 

http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated  by Public Law  95-452, as amended, is to protect 
the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of 
beneficiaries served by those programs.  This statutory mission is carried out through a nationwide network of audits, 
investigations, and inspections conducted by the following operating components: 
Office of Audit Services 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with its own audit 
resources or by overseeing audit work done by  others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are  intended to provide independent 
assessments of HHS programs and operations.  These assessments help reduce waste, abuse, and mismanagement 
and promote economy and efficiency throughout HHS. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the 
public with timely, useful, and reliable information on significant issues. These evaluations focus on preventing fraud, 
waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs.  To promote 
impact, OEI reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct 
related to HHS programs, operations, and beneficiaries.  With investigators working in all 50 States and the District of 
Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, State, 
and local law enforcement authorities. The investigative efforts of OI often lead to criminal convictions, administrative 
sanctions, and/or civil monetary penalties. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and 
opinions on HHS programs and operations and  providing all legal support for OIGs internal operations. OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims 
Act, program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG also negotiates and 
monitors corporate integrity agreements.  OCIG renders advisory opinions, issues compliance program guidance, 
publishes fraud alerts, and provides other guidance to the health care industry concerning the  anti-kickback statute 
and other OIG enforcement authorities. 
 
 
   
 
  EXECUTIVE SUMMARY 
 
 
This report provides a visual representation of data on the workload activities of Medicare benefit integrity contractors in  
calendar years 2012 and 2013.  The report allows for a quick comparison of workload statistics across the 2 years, 
across contractors, and across Medicare programs; and it provides a baseline for reviewing contractors quantitative 
results over time.  The report provides descriptive information about the changes that occurred from 2012 to 2013 as  
well as the variation among contractors workload statistics.  However, the report does not examine the underlying  
causes of those changes or variations.     
The contractors include Program Safeguard Contractors, Zone Program Integrity Contractors, and the National Benefit  
Integrity Medicare Drug Integrity Contractor (MEDIC).  Activities that these contractors perform to detect and deter 
Medicare fraud include, but are not limited to, conducting fraud investigations; analyzing data to identify aberrant billing 
patterns; referring suspected cases of fraud to law enforcement; responding to law enforcements requests for 
information; and, in some cases, recommending  administrative actions such as revocations and  payment suspensions.   
Past Office of Inspector General (OIG) work has shown substantial variation among benefit integrity contractors with  
respect to the number of investigations they started and the number of cases that they referred to law enforcement.  It 
has  also shown that the contractors made limited use of proactive methods to identify potential fraud and abuse; and  
that they did not report workload statistics in a uniform manner.  In addition, previous OIG work has identified anomalies 
in contractors  workload statistics, which may highlight issues with the Centers for Medicare & Medicaid Services 
(CMSs) oversight of these contractors.  Although we have conducted previous studies on these individual contractor 
types, this is the first report to provide the results of benefit integrity activities across all of these contractors.   
As shown in Figure 1, some workload results for contractors increased overall from 2012 to 2013, such as the number of 
proactive projects started and the number of revocations recommended, while others, such as the number of cases 
referred to law enforcement, decreased.  
 
Figure 1: Overall Changes in Selected Workload Statistics from 2012 to 2013 
 DECREASES 
INCREASES 
 Investigations based on       Investigations from all sources   
proactive leads       Immediate advisements  
 Fraud Prevention System 
   Case referrals  
(FPS)-related investigations1  
   Requests for information  
 Proactive projects 
received and completed  
 Overpayment referrals and 
   Payment suspensions  
recoveries 
   Providers added to   
 Revocations   
prepayment medical review  
 Exclusions 
   Auto-deny edits  
 Civil monetary penalties 
   
Source:  OIG analysis of 2012 and 2013 data from CMS Analysis, Reporting, and Tracking System (CMS ARTS) and MEDIC workload statistics.  
 
1  In 2011, CMS established the FPSa predictive analytic systemto identify and prevent fraud, waste, and abuse in Medicare Parts A and B. 
 
   
 
While increases and decreases in workload  statistics from year to year may be caused by reasonable shifts in  
workload priorities, we believe that CMS should examine these changes to ensure that they align with its benefit 
integrity goals.  In addition, we found variation in the level of benefit integrity activities conducted by contractors in 
2012 and 2013, even when we accounted for differences in the size of contractors oversight responsibility and the 
amount paid for their contracts.  Although there may be valid reasons for the variation among contractors, we believe  
that CMS should examine the variation and, if necessary, take steps to address poor performance, share best 
practices, or clarify workload definitions.  The work of the benefit integrity contractorsas well as CMSs oversight of 
these contractorsis vital to the integrity of the Medicare  program.  CMS concurred with the following 
recommendations to:   
 	  Examine trends in workload statistics, determine the causes for the increases and decreases in 
workload statistics across years, and determine whether these changes align with CMSs benefit  
integrity goals.   
 	  Examine the variation in workload statistics among benefit integrity contractors andas 
appropriateidentify performance issues that need to be addressed, best practices that can be 
shared, and workload definitions that need to be clarified to ensure that contractors report data  
uniformly and in the way CMS intends.   
 
 
 
 
 
  TABLE OF CONTENTS 
 
 
BACKGROUND .................................................................................................................1 

RESULTS IN BRIEF...........................................................................................................4 

RECOMMENDATIONS ......................................................................................................6 

AGENCY COMMENTS .....................................................................................................7 
 
APPENDIXES ....................................................................................................................8 

A: 	WORKLOAD STATISTICS ...............................................................................8 

INVESTIGATIONS ............................................................................................9 

PROACTIVE PROJECTS ...............................................................................13 

IMMEDIATE ADVISEMENTS .........................................................................15 

CASE REFERRALS .......................................................................................16 

REQUESTS FOR INFORMATION .................................................................19 

OVERPAYMENTS ..........................................................................................21 

REVOCATIONS ..............................................................................................24 

EXCLUSIONS ................................................................................................26 

CIVIL MONETARY  PENALTIES .....................................................................27 

PAYMENT SUSPENSIONS ............................................................................28 

PREPAYMENT MEDICAL REVIEW ................................................................31 

AUTO-DENY  EDITS .......................................................................................34 

B: 	WORKLOAD STATISTICS BY CONTRACTOR .............................................36 

C: 	RANKING OF CONTRACTORS OVERSIGHT RESPONSIBILITY  AND 

WORKLOAD STATISTICS.............................................................................43 

D: 	METHODOLOGY............................................................................................55 

E: 	PREVIOUS OIG REPORTS ON BENEFIT INTEGRITY CONTRACTORS.....57 

F: AGENCY COMMENTS....................................................................................58 

ACKNOWLEDGMENTS ..................................................................................................60 

 
   
 
   
BACKGROUND 
 
This report provides information on the Medicare benefit integrity activities of Program Safeguard 
Contractors (PSCs), Zone Program Integrity Contractors (ZPICs), and the National Benefit Integrity 
Medicare Drug Integrity Contractor (MEDIC).  Past Office of Inspector General (OIG) work has shown 
substantial differences among these contractors with respect to the number of investigations they started 
and the number of cases they referred to law enforcement.  It has also shown that the contractors  made 
limited use of proactive methods to identify potential fraud and abuse; and that they did not report workload 
statistics in a uniform manner.  In addition, previous OIG work has identified anomalies in contractors  
workload statistics, which may highlight issues with the Centers for Medicare & Medicaid Services (CMSs) 
oversight of these contractors. This is the first report to provide the results of benefit integrity activities 
across all of these contractor types. 
Benefit Integrity Contractors  
CMS has contracted with PSCs and ZPICs to carry out benefit integrity activities for Medicare Parts 
A and B. CMS has been transitioning from PSCs to ZPICs, and ZPICs are now fully operational in six of 
seven geographical zones. In the remaining zone, the ZPIC contract has not been awarded; instead, there 
are four PSCs conducting benefit integrity activities in that zone.  For Medicare Parts C and D, CMS 
contracts with one MEDIC to carry out benefit integrity activities nationwide.  Figure 2 shows the names we 
use to identify PSCs and ZPICs in our report and the States in each zone.1 The six ZPICs oversee Parts A 
and B, Durable Medical Equipment (DME), and Home Health and Hospice (HHH) in their respective zones.  
In the PSC coverage area, these responsibilities are divided among the four PSCs.2 Figure 3 shows the 
amount paid to each contractor and the size of each contractors oversight responsibility in 2012 and 2013.  
 
 
Figure 2: Benefit Integrity Contractors Coverage Areas in 2012 and 2013 
 
1  Not shown on this map are the U.S. territories of Northern Mariana Islands, American Samoa, and Guam (all in ZPIC 1s jurisdiction) and the U.S. Virgin Islands  
(in ZPIC 7s jurisdiction).    
2  PSC 1 oversees DME in all States in the PSC coverage area.  PSC 2 oversees Parts A and B in New Jersey and New York.  PSC 3 oversees Parts A and B in  
all States in the PSC coverage area except for New Jersey, New York, and Pennsylvania; oversees HHH for all States in the PSC coverage area; and oversees 
the counties of Arlington and Fairfax, VA, and the city of Alexandria, VA.  PSC 4 oversees Parts A and B in Pennsylvania.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   1 
   
 
Figure 3: Amount Paid to Contractor and Oversight Responsibility for Each Contractors Jurisdiction in  
2012 and 2013  
Amount of Paid  Amount of Paid  Number of  Number of 
Amount Paid  to   Amount Paid  to   Claims or  Claims or  Claims  Claims 
Contractor in  Contractor in  Expenditures in  Expenditures in  Processed in  Processed in 
Contractor   20121   20131   20122   20132   20123  20133 
PSC 1  $4,181,228  $4,160,076  $1,814,944,428   $1,555,687,942  11,640,641  10,768,163 
PSC 2  $8,139,871  $9,031,506  $32,755,864,765   $31,590,344,161  98,661,865  96,386,017 
PSC 3  $7,396,392  $8,162,781  $29,750,869,643   $29,554,086,368  85,729,052  86,658,779 
PSC 4  $4,328,598  $5,216,489  $13,731,774,602   $13,258,799,990  42,262,387  41,503,657 
ZPIC 1   $10,558,369  $11,649,892  $35,863,542,103   $35,330,473,103  93,590,619  91,712,988 
ZPIC 2   $11,086,474  $10,760,812  $37,668,706,944   $37,499,149,073  119,299,942  118,097,845 
ZPIC 3   $5,808,220  $8,769,293  $65,082,042,811   $63,122,742,569  207,536,737  202,903,810 
ZPIC 4   $12,244,080  $13,116,535  $36,191,979,987   $34,633,753,305  100,784,808  97,382,115 
ZPIC 5   $16,083,657  $16,740,734  $63,556,854,926   $62,074,919,758  205,241,991  203,503,883 
ZPIC 7   $24,196,730  $23,249,314  $26,726,385,968   $25,832,530,936  82,608,397  80,367,263 
MEDIC  $12,333,088  $13,559,830   $193,327,469,728  $205,908,214,464  NA  NA 
Total   $116,356,707  $124,417,262  $536,470,435,905  $540,360,701,669  1,047,356,439  1,029,284,520 
 
Source:  OIG analysis of 2012 and 2013 CMS Analysis, Reporting, and Tracking System (CMS ARTS) data, MEDIC workload statistics, and contractor oversight data.    
 
1  For PSCs and ZPICs, the amount paid to the contractor represents the amount paid for the contractors benefit integrity fee-for-service task order.  For the MEDIC, the amount  
paid represents the amount paid for the MEDICs national benefit integrity task order.    
2 For PSCs and ZPICs, the amount of paid claims represent the total claim payments processed by the  Medicare Administrative Contractors (MACs) for each jurisdiction.  For the  
MEDIC, the amount of expenditures represent the amount paid to all Part C and Part D plan sponsors.  
 
3  For PSCs and ZPICs, the number of claims represent the number of  claims processed in their jurisdictions by MACs.   
 
Benefit Integrity Contractors Activities and Reporting Requirements  
Activities that benefit integrity contractors perform to detect and deter Medicare fraud include, but are not 
limited to, conducting fraud investigations, analyzing data to identify aberrant billing patterns, referring 
suspected cases of fraud to law enforcement, and responding to law enforcements requests for 
information. In addition, PSCs and ZPICs recommend administrative actions such as revocations, 
exclusions, and payment suspensions. 
PSC and ZPIC Reporting Requirements. PSCs and ZPICs are required to report to CMS their monthly 
workload statistics related to their benefit integrity activities. CMS tracks and analyzes the statistics using 
an online system called CMS ARTS.   
The Small Business Jobs Act of 2010 required CMS to develop predictive analytics to identify and prevent 
payment for improper claims.  In June 2011, CMS established the Fraud Prevention System (FPS) to 
identify and prevent fraud, waste, and abuse in Medicare Parts A and B.  CMS uses the FPS to run 
predictive analytics on all Medicare fee-for-service claims prior to payment.  When the FPS identifies 
suspicious activity, it automatically generates leads for PSCs and ZPICs to investigate.  The FPS is part of 
CMSs program integrity strategy to address fraud.  PSCs and ZPICs report FPS-related workload statistics  
in CMS ARTS monthly.      
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   2 
   
 
MEDIC Reporting Requirements. The MEDIC is required to submit its performance metrics (hereinafter 
referred to as workload statistics) to CMS each month.  Unlike PSC and ZPICs, the MEDIC performs 
benefit integrity activities nationwide, rather than in individual zones across the country.  The MEDICs 
workload statistics include, but are not limited to, the number of investigations started, the number of 
immediate advisements and case referrals sent to law enforcement, and the number of requests for 
information completed. 
Methodology 
For the four PSCs and six ZPICs, we extracted from CMS ARTS the workload statistics for calendar years 
2012 and 2013.1  From CMS, we obtained the MEDICs 2012 and 2013 monthly workload statistics.  
Additionally, we obtained from CMS the amounts paid to each contractor in 2012 and 2013, as well as 
information on the contractors respective oversight responsibilities, such as the number of Medicare claims 
processed and the amount paid for these claims in each jurisdiction.   
Limitations 
This report contains information that benefit integrity contractors reported to CMS.  We did not 
independently verify this information.  This report provides descriptive information about changes and 
variations in workload statistics for 2012 and 2013; we did not determine the causes of those changes or 
variations, nor did we assess the quality of contractors activities.  
Standards 
This study was conducted in accordance with the Quality Standards for Inspection and Evaluation issued 
by the Council of the Inspectors General on Integrity and Efficiency. 
 
 
 
   
 
1 In the beginning of 2012, ZPIC 3 was transitioning into its oversight responsibility.  Therefore, ZPIC 3 has only 8 months of  workload statistics  
for 2012.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   3 
   
RESULTS IN BRIEF  
 
 
Proactive Investigations: The percentage of PSC and ZPIC investigations based on 
     +   
proactive leads increased from 8 percent in 2012 to 12 percent in 2013.  Investigations 
   
and case referrals based on external leads, versus proactive leads, were not reported 
 
  
separately in the MEDICs workload statistics.   
 
  
    FPS  FPS-related Investigations: The percentage of FPS-related investigations that PSCs 
 
  and ZPICs started more than doubled, from 9 percent in 2012 to 23 percent in 2013.  
   
   
Proactive Projects: The number of proactive projects that benefit integrity contractors 
Workload 
  started increased by nearly two-thirds from 2012 to 2013. 
Statistics 
 
Trending  Overpayments: Both the amount of overpayments that PSCs and ZPICs referred and 
Upward  the amount of overpayments recovered increased from 2012 to 2013. 
from 2012 
 
to 2013   Revocations: The number of revocations that ZPICs recommended increased 
 
15 percent from 2012 to 2013. 
 
 
REVOKED  
 
Exclusions: The number of providers recommended for exclusion increased from 0 to 3 
  between 2012 and 2013. 
 
Civil Monetary Penalties: The number of civil monetary penalties recommended 
  increased from 2012 to 2013; PSCs and ZPICs recommended four civil monetary  
penalties in 2012 and 2013 combined. 
 
 
 
  Investigations: Benefit integrity contractors started 36 percent fewer investigations in 
 
  2013 than in 2012.  
   
Immediate Advisements:  The number of immediate advisements sent to law 
Workload  
 
enforcement decreased by over 40 percent from 2012 to 2013. 
Statistics   
Trending    Case Referrals: The number of cases referred to law enforcement decreased by  
Downward    17 percent from 2012 to 2013. 
 
from 2012 
Requests for Information: The number of requests for information that benefit integrity 
 
to 2013  
contractors received from law enforcement and completed declined overall from 2012  
 
  to 2013. 
 
Payment Suspensions:  The number of providers that PSCs and ZPICs recommended 
 
for payment suspensions decreased by 19 percent from 2012 to 2013.  
 
Prepayment Medical Review: The number of providers added to prepayment medical 
 
review decreased by 50 percent from 2012 to 2013. 
 
Auto-Deny Edits: The number of new auto-deny edits  that PSCs and ZPICs 
   
recommended decreased by nearly two-thirds from 2012 to 2013.  
 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   4 
   
 
 
 
Variation:  For certain workload statistics, such as the number of investigations started and 
 
the amount of overpayments referred, there was considerable variation across contractors 
 
even after adjusting the data for differences in contractors oversight responsibilities and 
 
contract payment amounts. 
 
 
Appendixes 
 
   Appendix A provides more detailed information on each type of activity and its related workload 
statistics, including a variety of graphics to depict contractors results.  
   Appendix B provides the results across all contractors for each workload statistic. 
   Appendix C provides a 1-page overview of each contractors workload statistics showing how the 
contractors results rank in comparison to those of other contractors. 
   Appendix D provides a detailed methodology.  
   Appendix E provides information on previous OIG reports on benefit integrity contractors.  
   Appendix F provides CMSs comments on this report.   
 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   5 
   
RECOMMENDATIONS  
 
This report builds upon previous OIG studies regarding benefit integrity contractors.  In addition to making 
new recommendations, it provides further support for some of our prior recommendations.  Given that the 
work of the benefit integrity contractorsas well as CMSs oversight of these contractorsis vital to the 
oversight of the Medicare program, we recommend that CMS:   
Examine trends in workload statistics, determine the causes for the increases and decreases in 
workload statistics across years, and determine whether these changes align with CMSs benefit 
integrity goals.  
Certain workload statisticssuch as the number of proactive projects initiated, the amount of 
overpayments referred, and the number of revocations recommendedincreased from 2012 to 2013.  In 
contrast, other workload statisticssuch as the number of investigations, the number of case referrals, and 
the number of payment suspensionsdecreased from 2012 to 2013.  There may be valid reasons for these 
changes; however, CMS should review current trends to determine the underlying causes for the most 
significant increases and decreases across years, and determine whether these changes align with its 
benefit integrity goals. 
Examine the variation in workload statistics among benefit integrity contractors andas 
appropriateidentify performance issues that need to be addressed, best practices that can be 
shared, and workload definitions that need to be clarified to ensure that contractors report data 
uniformly and in the way CMS intends. 
Benefit integrity contractors differed in the amounts they were paid and the size of their oversight 
responsibilities.  However, even after we adjusted their workload data to account for these differences, we 
found considerable variability among contractors in 2012 and 2013 for certain workload statistics, such as the 
number of investigations started and the amount of overpayments referred.  Previously OIG has 
recommended that CMS perform a timely review of the data for each contractor and across contractors to 
detect any anomalies in workload reporting. CMS has addressed this prior recommendation by requiring staff 
to review CMS ARTS at least once a month and compare the workload for their respective contractors with 
contractors of similar size and scope to help gauge workload variation.  However, CMS needs to take further 
steps to use workload data effectively to help address variations across contractors that are due to differences 
in contractors performance and/or to differences in the ways that contractors report workload data.   
There may be valid reasons for the variation among contractors.  However, to the extent CMS determines 
that the variation reflects differences in contractors performance, we recommend that CMS address any 
issues with its contractors and identify best practices.  If the variation is due to the way contractors report 
the data, CMS should clarify its workload definitions to ensure that contractors report data in the way CMS 
intends. For example, PSCs and ZPICs were not consistent in reporting whether the number of 
FPS-related payment suspensions was the number recommended or the number implemented.  In 
addition, PSCs and ZPICs were not consistent in categorizing FPS-related investigations; some contractors 
counted them as proactive investigations, whereas others counted them as investigations based on 
external leads.    
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   6 
   
AGENCY COMMENTS  
 
CMS stated that it takes many steps to ensure proper oversight of the MEDIC, ZPICs, and PSCs including 
meeting routinely with contractors to discuss workload and outcomes and performing quarterly evaluations 
with the contractors to provide timely feedback and oversight.  CMS also explained that it conducts 
recurring meetings with senior managers and key personnel from each ZPIC and PSC to discuss CMS's 
goals and strategies and aligning contractor activities to those goals.   
 
CMS concurred with both of our recommendations. In response to our first recommendation, CMS stated 
that it would determine whether changes in workload statistics across years align with CMS's program 
integrity goals.  In response to our second recommendation, CMS stated that it already engages in 
comprehensive oversight of the MEDIC, ZPICs, and PSCs. However, to address workload variations as a 
result of the way contractors report workload data, CMS stated it is developing the Unified Case  
Management (UCM) system. The UCM system will serve as a central repository to track leads, monitor 
audit progress, and collect contractors' workload statistics in a unified manner.  Appendix F contains the full 
text of CMSs comments. 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   7 
   
APPENDIRXE AC:O  WMOMREKNLDOAATIDO SNTSA TISTICS  
 
 
 
 
 
 
 
 
 
Investigations  Proactive  Immediate 
 
  Projects   Advisements  
 
 
 
 
 
 
  Case  Requests for  Overpayments 
 
  Referrals   Information  
 
 
 
 
 
 
REVOKED 
 
 
Revocations     Exclusions   Civil Monetary 
Penalties 
 
 
   
Auto-Deny 
Edits  
Payment  Prepayment  Auto-Deny
Suspensions   Medical Review   Edits  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   8 
   
INVESTIGATIONS  
 
Highlight 
 
Benefit integrity contractors started 36 percent fewer investigations in 2013 than in 2012. 
 
Workload Activity  
 
PSCs, ZPICs, and the MEDIC are required to investigate potential fraud and abuse.  Investigations 
may be based on external leads, such as complaints, or proactive sources, such as data analysis.   
 
 
Investigations Started 
 
Figure 4: The number of investigations started by benefit integrity contractors decreased 36 percent 
from 2012 to 2013.   
2012  2013 
 
   8,197 
5,243 
 
 
36%
 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
 
 
Investigations Started, by Contractor 
 
 
  Figure 5: All but two contractors started fewer investigations in 2013 than in 2012.1  
2000  1881  1894 
2012  2013 
1800 
1600 
1400  1349 
1200 
1119 
1000  875 
800 
816 
609  571 
600  710 
385 
348 
339 
400 
226 
442 
135  348 
200  259  313  290 
239 
177 
0  115 
   Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
  1 According to CMS,  ZPIC 5 had a large decrease between 2012 and 2013 in the number of investigations it started because of a complaint-screening pilot that 
allowed for the improved vetting of leads prior to opening investigations.   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   9 
   
 
Number of Investigations Started per $1 Billion in Paid Claims/ Expenditures    
 
 
Figure 6: Variation in the number of investigations started by benefit integrity contractors could not 
be explained solely by differences in the sizes of their respective oversight responsibilities.1 
D 
2012  2013 
100 
90 
80 
70 
60 
50 
40 
30 
20 
10 
0 
 
   Source:  OIG analysis of 2012 and 2013 CMS ARTS data, MEDIC workload statistics, and contractor oversight data. 
  1  For PSCs and ZPICs, we define oversight responsibility as the amount of claims paid in their respective jurisdictions.  For the MEDIC, we define oversight  
responsibility as the amount paid to all Part C and Part D plan sponsors. 
 
Investigations Started, by Service Type  
 
Figure 7: In both 2012 and 2013, the highest percentage of investigations started was related to 
Part B services.1, 2 
2012  2013
 
 
 
Parts C 
    Parts C 
and D 
    and D 
  23%  Part B  26%  Part B 
  32% 
38% 
 
 HHH 
Part A 
  10%   
11% 
 
Part A  DME 
  DME 
11%  25%  HHH 
  14%
12% 
   
   
 
  8,197  5,243 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
  1 Although DME services are Part B services, they are reported separately in CMS ARTS.  For HHH services, ZPICs report these services separately in CMS ARTS, 
  whereas PSCs report them as Part A services.    
 2  The percentages for 2012 and 2013 do not total 100 percent because of rounding.   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   10 
   
 
 
Investigations Started  Proactive and External Leads  
 
Figure 8: Although the percentage of investigations based on proactive leads increased from 2012 
to 2013, most PSC and ZPIC investigations were based on external rather than proactive leads in 
both years. Investigations based on external leads, versus proactive leads, were not reported 
separately in the MEDICs workload statistics, so they are not included here. 1      
2012  2013 
Proactive 
Proactive 
Leads 
Leads 
12% 
8% 
PSCs 
and  External  External 
ZPICs   Leads  Leads 
88% 
92% 
6,303  3,894 
Source:  OIG analysis  of 2012 and 2013 CMS ARTS data.  
 1  PSCs and ZPICs varied as to how they categorized FPS-related investigations; some contractors may have counted them as investigations based on proactive 
leads and others may have counted them as investigations based on external leads.  
 
Investigations Started  FPS-related 
 
Figure 9: Although the overall number of investigations decreased, the percentage of FPS-related 
investigations started by PSCs and ZPICs more than doubled from 2012 to 2013.1   
2012  2013 
FPS   
9%  FPS 
23% 
PSCs 
and 
Non-FPS 
ZPICs   Non-FPS 
91% 
78% 
6,303  3,894 
 
Source: OIG analysis of 2012 and 2013 CMS ARTS data. 
 
1 The percentages for 2013 do not total 100 percent because of rounding. 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   11 
   
 
 
Number of Investigations Started per $1 Million Paid to Contractor  
Figure 10:  The number of investigations started varied among contractors even after adjusting the data  
for differences in the amounts the contractors were paid.  
180 

x
2012
  2013

160 

140 
120 
100 
80 
60 
40 
20 
0 
 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data, MEDIC workload statistics, and contractor oversight data.  
 
 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   12 
   
PROACTIVE PROJECTS  
 
Highlight 
 
The number of proactive projects started by benefit integrity contractors increased 
by nearly two-thirds from 2012 to 2013. 
 
Workload Activity  
 
Benefit integrity contractors conduct proactive data analysis projects to identify patterns or trends 
that may indicate fraudulent billing.  These projects may or may not result in an investigation. 
   
 
Proactive Projects Started 
Figure 11:  The number of proactive projects that benefit integrity contractors started increased by 
62 percent from 2012 to 2013. 
  2012  2013 
 
 
62% 
 
 
 
259  420 
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
 
Proactive Projects Started, by Contractor Type  
Figure 12: The number of proactive projects that benefit integrity contractors started increased 
substantially from 2012 to 2013, particularly for the MEDIC.   
 
   
2013
2012 
54% 
PSCs and 
ZPICs  
371 
241 
172% 
MEDIC  
49 
18 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   13 
   
Proactive Projects Started, by Contractor  
 
Figure 13: Three contractors started the majority of proactive projects in 2012 and 2013.  
2012 
PSC 1  1  1 
PSC 2  43  88  2013 
PSC 3  11  13  D
PSC 4  0  9 
ZPIC 1  94  70 
ZPIC 2  32  33 
ZPIC 3  4  28 
ZPIC 4  1  5 
ZPIC 5  5  23 
ZPIC 7  50  101 
MEDIC  18  49 
0  20  40  60  80  100  120  140  160  180 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
 
Number of Proactive Projects Started per $1 Million Paid to Contractor  
 
Figure 14: The number of proactive projects started varied among contractors even after adjusting 
the data for differences in the amounts the contractors were paid.1 
12 
x
2012  2013 
10 
8 
6 
4 
2 
0 
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data, MEDIC workload statistics, and contractor oversight data.  
  1  In 2012, PSC 4 started no proactive projects and PSC 1, ZPIC 3, ZPIC 4, and ZPIC 5 started less than one proactive project per  $1 million paid to the contractor. In  
2013, PSC 1 and ZPIC 4 started less than one proactive project per $1 million paid  to the contractor. 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   14 
   
IMMEDIATE ADVISEMENTS  
 
Highlight 
 
The number of immediate advisements that benefit integrity contractors sent to law
enforcement decreased by over 40 percent from 2012 to 2013. 
 
Workload Activity  
 
Immediate advisements are fraud or abuse allegations that benefit integrity contractors are required 
to send directly to law enforcement without conducting an investigation. 
 
Immediate Advisements  
 
Figure 15: The number of immediate advisements sent to law enforcement decreased by 44 percent 
from 2012 to 2013.  2012   2013  
 
 
 
 
 
  1,153  44%  640 
 
 
  Source: OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
 
Immediate Advisements, by Contractor  
 
Figure 16: ZPIC 4 sent no immediate advisements in 2012 and 2013. For the remaining contractors, 
the number of immediate advisements sent to law enforcement decreased from 2012 to 2013. 
 
 
250 
2012  2013  233 
213 
202 
200 
164 
171 
150 
118 
138 
100  95  123 
94 
55 
50  34 
28 
43 
11  45 
5  10 
0  8  3  00 
 
Source: OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
Medicare Benefit Integrity Contractors Activities in 2012 and 2013: A Data Compendium (OEI-03-13-00620)                                   15 
   
CASE REFERRALS 
 
Highlight 
 
Benefit integrity contractors referred 17 percent fewer cases to law enforcement in 2013 than 
in 2012.  
 
Workload Activity  
 
When a benefit integrity contractors investigation substantiates an allegation of potential fraud or abuse, 
the contractor refers it as a case to law enforcement. 
 
Case Referrals 
 
Figure 17: The number of cases referred to law enforcement decreased 17 percent from 2012 to 2013.1    
  2012  2013 
 
 
  
768  639 
 
Case   Case  
 
Referrals  Referrals  
 
17% 
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
  1 The MEDIC included immediate advisements in its number of case referrals reported to CMS.  
 
Number of Case Referrals per $1 Million Paid to Contractor  
 
Figure 18: The number of cases referred varied among contractors even after adjusting the data for 
differences in the amounts the contractors were paid.1, 2  
40 
x
2012  2013 
35 
30 
25 
20 
15 
10 
5 
0 
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data, MEDIC workload statistics, and contractor oversight data.  
 
1  The MEDIC included immediate advisements in its number of case referrals reported to CMS.   
 
  2 In 2012 and 2013, PSC 4 and ZPIC 3 referred less than one case per $1 million in payments.   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   16 
   
Case Referrals  Proactive and External Leads  
 
Figure 19: In 2012 and 2013, the majority of the PSCs and ZPICs case referrals resulted from 
 
investigations based on external rather than proactive leads.1 
2013 
2012 
Proactive  Proactive 
PSCs 
Leads  External  Leads  External 
and  38%  Leads  38%  Leads 
ZPICs   62%  62% 
339  255 
 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
1  Case referrals based on external versus proactive leads were not reported separately in the MEDICs workload statistics, so they are not included here.  
 
 
PSCs and ZPICs Estimated Dollar Amount Associated with Case Referrals and the MEDICs 
Potential Dollar Impact of Case Referrals 
 
Figure 20: The estimated dollar amount associated with PSC and ZPIC case referrals decreased 
slightly from 2012 to 2013. However, the potential dollar impact of MEDIC case referrals increased 
six times from 2012 to 2013.1, 2   
 
2012  2013
 
 
$   $  
PSC s and ZPICs  
Estimated Amount  
Associated With 
5% 
Case Referrals   $349 Million   $331 Million 
 
 
 
   
$ 
MEDIC   $  
Potential Dollar    501% 
Impact of Case 
Referrals  
$973 million   $5.85  Billion 
 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
 
 1 Because of differences in the parts of the Medicare program, the PSCs and ZPICs differ from the MEDIC in how they calculate the estimated amount associated 
 with case referrals.   
 
 2  According to CMS, an immediate advisement referral involving a large retail pharmacy accounted for nearly $4 billion of the potential dollar impact of the MEDICs 
 
case referrals in 2013. 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   17 
   
Estimated Amount Associated With PSCs and ZPICs Case Referrals by Contractor  
 
Figure 21: Half of the total dollar amount associated with PSC and ZPIC case referrals was 
 
associated with case referrals from ZPIC 4 in both 2012 and 2013.  PSC 4 did not report any amounts
 associated with case referrals in 2013 even though it referred two cases that year.  
 
2012  2013 
1%  1% 
PSC 4 
4%  1%  1%  1% 
15%  7%  <1%  13%  6%  2% 
5% 
19% 
16% 
50%  56% 
1%  ZPIC 3 
<1% 
$349 Million  $331  Million 
PSC 1  PSC 2  PSC 3  PSC 4  ZPIC 1  ZPIC 2  ZPIC 3  ZPIC 4  ZPIC 5  ZPIC 7  x
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
 
Estimated Amount Associated With PSCs and ZPICs  Case Referrals per $1 Billion in Paid Claims  
 
Figure 22: Variation in the dollar amount associated with PSC and ZPIC case referrals could not be 
explained solely by differences in the size of contractors respective oversight responsibilities.1 
$6,000,000 
x 
2012  2013 
$5,000,000 
$4,000,000 
$3,000,000 
$2,000,000 
$1,000,000 
$0 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS and contractor oversight data.   
 
1  In 2012, the amount associated with PSC 4s case referrals was $2,088 per $1 billion in paid claims. In 2013, there was $0 associated with PSC 4s case 
 
referrals, even though it  referred two cases in 2013.  In 2013, the amount associated with ZPIC 3s case referrals was $12,347 per $1 billion in paid claims.    
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   18 
   
REQUESTS FOR INFORMATION 
 
Highlight 
 
The number of requests for information that benefit integrity contractors received 
from law enforcement and completed declined overall from 2012 to 2013.      
 
Workload Activity  
 
Federal, State, or local law enforcement agencies may request beneficiary or provider information 
from benefit integrity contractors to further their investigations or prosecutions, and benefit 
integrity contractors respond to these requests.    
 
Requests for Information, Received and Completed  
 
Figure 23: The number of requests for information, received and completed, declined overall, by 
8 percent and 11 percent respectively, from 2012 to 2013.1, 2 
                2012                       2013  
 
 
Requests for
  Information, 
Received 
 
8%  
 
5,042   4,647  
 
 
 
 
Requests for
 
Information, 
Completed     
11%  
 
5,179     4,629  
 
Source: OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
1  The MEDIC workload statistics include the number of requests for  information received from OIG,  the Department of Justice (DOJ), and other 
entities, but they do not include the number of  requests for information completed for entities other than OIG and DOJ.  The MEDIC received 
1 request for  information from an entity other than DOJ or OIG in 2012 and 11 requests in 2013.  
2 The number of requests for information completed is not a subset of the number  received because the request may have been made in a year prior  
 
to the one in which it was completed.  
 
 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   19 
   
 
Requests for Information, Received and Completed,  by Contractor  
 
Figure 24: The number of requests for information, received and completed, decreased for nearly 
half of contractors from 2012 to 2013.1    
Number of Requests for Information Received 

1200 

x 
2012  2013 
1000 
800 
600 
400 
200 
0 
 
 
 
Number of Requests for Information Completed 
1200 
x 
2012  2013 
1000 
800 
600 
400 
200 
0 
 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics. 
 
 
 1 The number of  requests for information completed is not a subset of the number  received because the request may have been made in a year prior  to the one in 
  which it was completed.   
 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   20 
   
OVERPAYMENTS 
 
 
Highlight 
 
Both the amount of overpayments PSCs and ZPICs referred and the amount of 
overpayments recovered increased from 2012 to 2013. 
 
Workload Activity  
 
PSCs and ZPICs refer overpayments identified through investigations and cases to Medicare 
Administrative Contractors (MACs) for collection. The MACs are responsible for collecting the 
overpayments from providers and reporting the amount recovered to the PSCs and ZPICs.   
 
Overpayments Referred and Recovered  
 
Figure 25:   The amount of overpayments that PSCs and ZPCs referred and that MACs recovered 
increased, by 8 percent and 7 percent respectively, from 2012 to 2013.1, 2  
 
  2012   2013  
 
 
Overpayments 
  8% 
Referred 
 
 
 
 
$375 million   $405 million  
 
 
 
 
 
 
 
Overpayments 
7% 
  Recovered  
 
  $90 million   $97 million  
 
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
1  The amount of overpayments recovered may not be a subset of the amount  referred because the referral may have been made in a year prior to the one in 
which the overpayment was recovered.     
2  Using the rounded numbers of $90 million and $97 million for overpayments recovered, the percentage increase is 8 percent.  Using the numbers $90,076,306 
 
and $96,694,400, the percentage increase is 7 percent.   
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   21 
   
 
Overpayments Referred, by Contractor  
 
Figure 26: ZPICs 5 and 7 accounted for the greatest percentage of overpayment dollars referred in 2012 and 2013.1   
2012  2013 
2%  1% 
10%  3%  8% 
3% 
3% 
24%  22%  7% 
4% 
4% 
3% 
4% 
7% 
8% 
26% 
40% 
17% 
5% 
$375 Million  $405 Million 
PSC 1  PSC 2  PSC 3  PSC 4  ZPIC 1  ZPIC 2  ZPIC 3  ZPIC 4  ZPIC 5  ZPIC 7  x
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data.  
  1 The percentages for 2012 do not total 100 percent because of rounding. 
 
Overpayments Referred, by Service Type  
 
Figure 27: The greatest percentage of overpayment dollars referred by PSCs and ZPICs were for 
Part B services in both years.1 
 
   
2012  2013 
Part A  Part A 
Part B  16%  15% 
Part B 
30% 
38% 
DME 
DME  20% 
28% 
HHH  HHH 
26%  27% 
$375 Million  $405 Million 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data.  
1 Although DME services are Part B services, they are reported separately in CMS ARTS.  For HHH services, ZPICs report these services separately in CMS ARTS,  
whereas PSCs report them as Part A services.    
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   22 
   
 
 
Amount of Overpayments Referred per $1 Billion in Paid Claims  
 
 
Figure 28: Variation in the amount of overpayments that PSCs and ZPICs referred could not be 
explained solely by differences in the size of these contractors respective oversight responsibilities. 
 
$4,000,000 
x
2012  2013 
$3,500,000 
$3,000,000 
$2,500,000 
$2,000,000 
$1,500,000 
$1,000,000 
$500,000 
$0 
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS and contractor oversight data.  
 
Amount of Overpayments Recovered,  by Contractor  
 
Figure 29: The greatest percentage of overpayment  dollars that MACs recovered was associated with 
referrals from ZPIC 5 in both 2012 and 2013.1 
2012 
2013 
2% 
1% 
3% 
8%  12%  7% 
11% 
4%  3% 
6% 
2% 
7% 
3% 
36%  2% 
10%  43% 
21% 
19% 
3% 
$90 Million   $97 Million 
 
PSC 1  PSC 2  PSC 3  PSC 4  ZPIC 1  ZPIC 2  ZPIC 3  ZPIC 4  ZPIC 5  ZPIC 7  x
 
 
 
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data.  
1 The percentages for 2012 and 2013 do not total 100 percent because of rounding.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   23 
   
REVOCATIONS 
 
Highlight 
 
The number of revocations that ZPICs recommended increased by 15 percent from 2012  
to 2013.  
 
Workload Activity  
 
PSCs and ZPICs may recommend to CMS that a providers Medicare billing privileges be revoked.  For 
example, CMS may implement a revocation when the provider has been excluded from participation in 
any Federal health care program, is not in compliance with enrollment requirements, or has abused his 
or her billing privileges. 
 
Revocations Recommended  
 
Figure 30:   The number of revocations ZPICs recommended increased from 2012 to 2013.1  
2012   2013  
 
 
  15% 
 
  RECOMMENDED  RECOMMENDED 
  213   246  
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
1 PSCs were not required to report revocations in CMS ARTS.   
 
Revocations Recommended, by ZPIC  
 
Figure 31: ZPIC 4 and ZPIC 7 recommended the greatest percentage of revocations in 2012 and 2013.1, 2 
2012  2013 
ZPIC 1 
5% 
ZPIC 2 
4% 
ZPIC 1 
13%  ZPIC 2  ZPIC 7 
5%  32% 
ZPIC 7  ZPIC 3 
48%  ZPIC 3  9% 
7% 
ZPIC 4  ZPIC 5 
17%  12%  ZPIC 4 
ZPIC 5  39% 
10% 
213  246 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data.  
  1 PSCs were not  required to report revocations in CMS ARTS.  
2 The percentages for 2013 do not total 100 percent because of rounding.    
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   24 
   
 
Revocations Implemented 
 
Figure 32:   The number of ZPIC-recommended revocations that were implemented by CMS increased 
22 percent from 2012 to 2013.1  
 
2012   2013  
 
 
22% 
 
 
  REVOKED   REVOKED  
  101   123  
   
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
1 PSCs were not  required to report revocations in CMS ARTS.  
 
 
 
Revocations Implemented, by Contractor  
 
 
 
Figure 33: ZPIC 7 accounted for the greatest percentage of revocations implemented by CMS in 2012 
and 2013.1, 2   
 
2012 
2013 
ZPIC 1  ZPIC 1 
ZPIC 2 
14%  9%  ZPIC 2 
4%  ZPIC 3 
7% 
3% 
ZPIC 7 
35% 
ZPIC 3 
ZPIC 7  11% 
56% 
ZPIC 4 
ZPIC 4 
33% 
8%
ZPIC 5 
ZPIC 5 
7% 
14% 
101  123
 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
1 PSCs were not  required to report revocations in CMS ARTS.  
  2 The percentages for 2013 do not total 100 percent because of rounding.    
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   25 
   
EXCLUSIONS 
 
 
Highlight 
 
PSCs did not recommend any exclusions in 2012 or 2013; ZPICs recommended zero 
exclusions in 2012 and three in 2013.   
 
Workload Activity  
 
PSCs and ZPICs may recommend exclusions to OIG. OIG has the authority to exclude providers 
from participation in all Federal health care programs for convictions related to certain criminal 
offenses such as Medicare fraud, patient abuse or neglect, or for a number of other offenses.   
 
 
Exclusions Recommended 
 
Figure 34: PSCs and ZPICs did not recommend any exclusions in 2012.   ZPIC 3, ZPIC 5, and ZPIC 7 
each recommended one exclusion in 2013.   
 
 
2012  2013 
 
 
 
 
 
 
 
 
 
0  
 
 
 
  3  
 
 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
 
 
 
 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   26 
   
CIVIL MONETARY PENALTIES 
 
Highlight 
 
PSCs and ZPICs recommended four civil monetary penalties (CMPs) in 2012 and 2013 
combined.  
 
 
Workload Activity  
 
PSCs and ZPICs may recommend that CMS or OIG impose CMPs on providers for certain 
violations, such as presenting a claim that the provider knows is for an item or service that was not 
provided or that is false and fraudulent.    
 
 
CMPs Recommended 
 
Figure 35:   The number of CMPs recommended increased from one to three from 2012 to 2013.  

ZPIC 2 recommended one CMP in 2012 and two in 2013.  ZPIC 5 recommended one CMP in 2013. 
 
 
 2012         2013  
 
Civil Monetary 

Penalties 

Recommended 

 
 
  1  3  
 
 
 
   
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   27 
   
PAYMENT SUSPENSIONS 
 
Highlight 
 
The number of providers that PSCs and ZPICs recommended for payment suspension 
decreased by 19 percent from 2012 to 2013.  
 
 
Workload Activity  
 
PSCs and ZPICs may recommend providers to CMS for payment suspension. CMS may suspend 
payments to providers when there is fraud or willful misrepresentation or when the provider fails to 
furnish records and other requested information needed to determine the amounts due to the 
provider.   
 
 
Payment Suspensions Recommended  
 
Figure 36:   The number of providers recommended for payment suspension decreased 19 percent 
from 2012 to 2013.1   
 
 
 
  2012  2013 
19% 
202   164 
Providers  Providers 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
1 According to CMS,  many large-scale investigations led to payment suspensions in 2012.    
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   28 
   
 
Payment Suspensions Recommended,  by Contractor  
 
Figure 37: ZPIC 4 recommended more than 60 percent of all payment suspensions in 2012, but
15 percent in 2013. PSC 1 and PSC 4 did not recommend any payment suspensions in 2012.1, 2   
2012  2013 
1% 2% 
2%  3% 
2% 
7% 
7%  6%  10%  7%  1% 2% 
8% 
17% 
26% 
65%  18% 
15% 
202  164  
PSC 1  PSC 2  PSC 3  PSC 4  ZPIC 1  ZPIC 2  ZPIC 3  ZPIC 4  ZPIC 5  ZPIC 7  x
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data.  
  1 The percentages for 2012 and 2013 do not total 100 percent because of rounding.  
   2 According to CMS, ZPIC 4 had a high percentage of payment suspensions in 2012 because of a number of large-scale investigations that were resolved that year.    
 
Payment Suspensions Recommended,  by Service Type  
 
 
Figure 38: In 2012, the majority of payment suspensions recommended were for providers of HHH 
 
services. In 2013, the percentage of payment suspensions recommended for providers of HHH 
services decreased by half from 2012.  For the same time period, the percentage of payment
 
suspensions recommended for providers of Part B services nearly doubled. 1, 2  
2012  2013 
DME 
DME 
7% 
Part B  12% 
26% 
Part B 
47%  HHH 
Part A 
32% 
3%  HHH 
63% 
Part A 
9% 
202 
164 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data.  
 
  1  The percentages for 2012 do not total 100 percent because of rounding. 
2  Although DME services are Part B services, they are reported separately in CMS ARTS.  For HHH services, ZPICs report these services separately in 
 
CMS ARTS, whereas PSCs report them as Part A services.   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   29 
   
 
FPS-Related Payment Suspensions Recommended  
 
 
Figure 39: The number of FPS-related payment suspensions that PSCs and ZPICs recommended 
increased by nearly 300 percent from 2012 to 2013.1, 2    
140 
119 
120 
100 
80 
60 
40  32 
20 
0 
2012  2013 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data.  
 
 
1  PSCs and ZPICs may have reported the number of FPS-related payment suspensions recommended or the number  implemented.  
2  According to CMS,  the FPS-related payment suspensions should be a subset of all payment suspensions.  However, as shown in Figure 40, one ZPIC  
reported a greater number of FPS-related payment suspensions than its total number of payment suspensions.   
 
Payment Suspensions and FPS-Related Payment Suspensions Recommended, by Contractor  
 
Figure 40: In the workload statistics, FPS-related payment suspensions should be a subset of all 
payment suspensions. However, in 2013, one ZPIC reported a greater number of FPS-related 
payment suspensions than its total number of payment suspensions.1    
70 
All Payment Suspensions Recommended in 2013 
59 
60 
FPS-Related Payment Suspensions Recommended in 2013 
50  x 
42 
40 
29 
30  28  27 
24 
20  18  17 
11 
10 
10 
5 
4  4 
3 
1  1 
0  0  0  0 
0 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
1  According to CMS,  the FPS-related payment suspensions should be a subset of all payment suspensions.   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   30 
   
PREPAYMENT MEDICAL REVIEW 
 
Highlight 
 
The number of providers added to prepayment medical review decreased by 
50 percent from 2012 to 2013. 
 
 
Workload Activity  
 
PSCs and ZPICs may request that MACs put claims processing edits in place to identify a 
providers claims for prepayment medical review when aberrancies are detected in billing data. 
 
 
Prepayment Medical Review  
 
Figure 41:   The number of providers added to prepayment medical review decreased by half from 
2012 to 2013.1   
 
 
  2012 
2013 
 
 
1,262   630 
 
  50% 
 
 
 
 
 
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
  1  According to CMS,  the decrease in prepayment medical review resulted from a complaint-screening pilot  that reduced the need to  initiate prepayment  
  reviews and an emphasis by CMS to ensure th at prepayment  reviews were justified before they were established.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   31 
   
 
Prepayment Medical Review, by Contractor  
 
Figure 42: ZPIC 4, ZPIC 5, and ZPIC 7 had the greatest percentage of providers added to 
prepayment medical review in 2012 and 2013.1 
2012 

ZPIC 7 
17% 
ZPIC 5 
19%  11% 
Other 
Contractors 
1,262   6% 
26%
Providers  1% 
1% 
ZPIC 4  5%
2% 
38%  <1% 
 
2013 

ZPIC 7 
19% 
6% 
7% 
1% 
630   Other 
1% 
Providers   ZPIC 5  Contractors 
18%  44%  16% 
8% 
5% 
ZPIC 4 
19% 
PSC 1 
 PSC 2 
 PSC 3 
 PSC 4 
 ZPIC 1 
 ZPIC 2 
 ZPIC 3 
 ZPIC 4 
 ZPIC 5 
 ZPIC 7 
 x
   
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
  1 The percentages of providers for  Other Contractors in 2012 do not add up to 26 percent because of rounding.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   32 
   
 
Amount  Denied Based on All Prepayment Medical Review and FPS-Related Prepayment 
Medical Review  
 
Figure 43: The amount denied based on all prepayment medical review decreased from 2012 to 2013.  
However, the amount denied based on FPS-related prepayment medical review increased slightly. 
 
$160,000,000 
$140,000,000  $136,098,610 
$117,598,335 
$120,000,000 
$100,000,000 
$80,000,000 
$60,000,000 
$40,000,000 
$20,406,893  $21,227,503 
$20,000,000 
$0 
2012  2013 
Amount Denied Based on All Prepayment Review 
Amount Denied Based on FPS-Related Prepayment Review 
Dummy
  Source:  OIG analysis of 2012 and 2013 CMS ARTS data.  
 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   33 
   
AUTO-DENY EDITS 
 
Highlight 
 
The number of new auto-deny edits that PSCs and ZPICs recommended decreased 
by nearly two-thirds from 2012 to 2013. 
 
Workload Activity  
 
Auto-deny edits prevent payment for services that are not covered, incorrectly coded, or 
inappropriately billed. PSCs and ZPICs recommend auto-deny edits to the MACs for implementation. 
 
Auto-Deny Edits Recommended  
 
Figure 44:   The number of new auto-deny edits recommended decreased 61 percent from 2012 to 2013.  
2012    2013 
     
     
10,308    4,045   
 
Auto-Deny Edits  
Auto-Deny Edits  
61% 
 
 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
Amount Denied Based on All Auto-Deny Edits and FPS-Related Auto-Deny Edits 
 
Figure 45: The amount denied based on all PSC and ZPIC recommended auto-deny edits and based 
on FPS-related auto-deny edits decreased from 2012 to 2013. 
 
 
$ 120,000,000  $114,749,351  
Amount Denied Based on All Auto-Deny Edits 
Amount Denied Based on FPS-Related Auto-Deny Edits 
$100,000,000 
$79,452,045 
$80,000,000 
$60,000,000 
$40,000,000 
$20,000,000 
$4,835,319  $4,110,350 
$0 
2012  2013 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   34 
   
 
Auto-Deny Edits Recommended, by Contractor  
 
Figure 46: ZPIC 7 recommended over 70 percent of all auto-deny edits in both 2012 and 2013.  
 
 
2012 

Other PSCs and 
ZPIC 7 
ZPICs 
75% 
25% 
10,308  
2013 
Other PSCs and 
ZPIC 7 
ZPICS 
72% 
28% 
4,045
  
Source:  OIG analysis of 2012 and 2013 CMS ARTS data. 
 
 
 
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   35 
   
APPENDIX B:  WORKLOAD STATISTICS BY CONTRACTOR  
 
Benefit integrity contractors report monthly workload statistics to CMS.  Figure 47 provides workload statistics  
associated with each contractor for calendar years 2012 and 2013 as well as the minimum (MIN), maximum (MAX), 
and median value for each workload statistic.  All of the contractors report the same statistics, with some 
exceptions.  For example, in 2012 and 2013, CMS did not require PSCs to report the number of revocations they 
recommended.  Also, the MEDIC does not recommend administrative actions such as revocations, exclusions, civil 
monetary penalties, payment suspensions, prepayment medical reviews, or auto-deny edits.  The MEDIC also does 
not separately report activities that are based on proactive leads.  Additionally, the MEDIC does not refer 
overpayments for collection and does not conduct Fraud Prevention System (FPS)-related investigations.   
 
Figure 47: Benefit Integrity Contractors 2012 and 2013 Workload Statistics 
 
Percentage of  
Investigations  Percentage of   Number of 
Number of  Based on   FPS-Related   Number of  Immediate  
Contractor   Investigations   Proactive Leads   Investigations   Proactive Projects  Advisements  
   2012  2013  2012  2013  2012  2013  2012  2013  2012  2013 
PSC 1  115   135   13%  19%  4%   6%   1  1  11  5 
PSC 2  348  259   11%  18%  5%   14%  43   88  118   45  
PSC 3  339   313   2%   7%   10%  13%  11  13  55   8 
PSC 4  226   177   13%  5%  3%   19%  0  9  28   3 
ZPIC 1   609   290   3%   4%   13%  27%  94  70  34  10  
ZPIC 2   571   239   12%  5%   18%  62%  32  33  95  43  
ZPIC 31   710  875   1%   1%   3%   3%   4  28  164  123  
ZPIC 4   385   348   11%  20%  22%  14%  1  5  0  0 
ZPIC 5   1,881  442   <1%  23%  9%   46%  5  23  233  138  
ZPIC 7   1,119  816   23%  21%  5%   31%  50  101  213   94  
MEDIC  1,894   1,349   NA  NA  NA  NA  18   49   202   171  
TOTAL  8,197   5,243   8%   12%   9%   23%   259   420   1,153   640  
MIN  115   135   <1%  1%   3%   3%   0  1  0  0 
MAX  1,894   1,349   23%  23%  22%  62%  94  101  233  171  
MEDIAN  571  313   11%  13%  7%   16%2   11  28  95  43  
 
                       Continued  on  next  page  
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   36  
   
 
 
Figure 47: Benefit Integrity Contractors 2012 and 2013 Workload Statistics (Continued) 
 
Number of  Number of 
Number of  Requests for  Requests for 
Number of Case  Amount Associated with Case  Cases   Information,   Information,  
Contractor   Referrals  Referrals  Accepted   Received   Completed 
   2012  2013  2012  2013  2012  2013  2012  2013  2012  2013 
PSC 1  5  15   $2,872,548   $3,999,452   2  6  57  39  65  46  
PSC 2  20  18   $25,333,789   $20,554,539   11   15  244  273  256  271  
PSC 3  10   12   $3,349,368   $4,683,687   4  8  380  342  366  357  
PSC 4  1  2  $28,667   $0   0  1  126  196  130  191  
ZPIC 1   18  14   $16,782,312   $7,355,505   16   11  831  463  872  472  
ZPIC 2   94  28   $55,887,049   $62,408,253   50   25  253  360  315  324  
ZPIC 31   2  6  $3,474,596   $779,376   5  5  274  417  243  429  
ZPIC 4   87  99   $174,383,335    $186,099,736    32   33  876  523  846  529  
ZPIC 5   72  35   $52,067,827   $3,041,859   24   32  1,088   856  1,126   854  
ZPIC 7   30  26   $15,130,018   $41,660,048   14   12  443  689  487  692  
MEDIC  4293  3843  NA4  NA4   274   237  470  489  473  464  
TOTAL  768   639   $349,309,509   $330,582,455   432   385   5,042   4,647   5,179   4,629  
MIN  1  2  $28,667   $0   0  1  57  39  65  46  
MAX  429  384   $174,383,335   $186,099,736   274   237   1,088  856   1,126  854  
MEDIAN  20   18   $15,956,165   $6,019,596   14   12  380  417  366  429 
 
            Continued on next page  
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                                37  
     
 
 
Figure 47: Benefit Integrity Contractors 2012 and 2013 Workload Statistics (Continued)  
 
Contractor   Amount of Overpayments Referred  Amount of Overpayments Recovered  
   2012  2013  2012  2013 
PSC 1  $6,003,840   $4,289,702   $1,966,172   $926,017  
PSC 2  $36,132,797   $33,496,806   $10,443,363   $6,729,556  
PSC 3  $11,376,694   $12,178,748   $5,615,388   $2,642,464  
PSC 4  $9,950,243   $26,595,400   $2,037,924   $3,400,024  
ZPIC 1   $13,858,237   $16,892,314   $2,825,043   $2,785,678  
ZPIC 2   $12,602,608   $26,341,201   $8,654,999   $6,397,790  
ZPIC 31   $14,011,756   $68,909,038   $2,402,562   $2,091,536  
ZPIC 4   $29,269,446   $20,891,102   $16,948,585   $19,904,797  
ZPIC 5   $151,368,715    $104,837,518    $32,004,481   $41,156,043  
ZPIC 7   $90,861,223   $90,883,843   $7,177,789   $10,660,495  
MEDIC  NA  NA  NA  NA 
TOTAL  $375,435,559    $405,315,672    $90,076,306   $96,694,400  
MIN  $6,003,840  $4,289,702  $1,966,172   $926,017  
MAX  $151,368,715    $104,837,518    $32,004,481   $41,156,043  
MEDIAN  $13,934,997   $26,468,301   $6,396,589   $4,898,907  
 
                Continued on next page  
 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   38  
   
 
 
Figure 47: Benefit Integrity Contractors 2012 and 2013 Workload Statistics (Continued) 
 
Number of  Number of  Number of All Payment  Number of FPS-Related 
Revocations   Revocations   Suspensions  Payment Suspensions  
Contractor   Recommended   Implemented   Recommended   Recommended  
   2012  2013  2012  2013  2012  2013  2012  2013 
PSC 1  NA5  NA5  NA5  NA5   0  5  0  0 
PSC 2  NA5  NA5  NA5  NA5   3  11   0  4 
PSC 3  NA5  NA5  NA5  NA5   5  4  0  0 
PSC 4  NA5  NA5  NA5  NA5   0  1  0  0 
ZPIC 1   27   12   14   11  4  3  4  0 
ZPIC 2   10   9  4  8  13  28   1  27  
ZPIC 31   14  23   11   4  17   296   6  596  
ZPIC 4   37  95   8  40   131   24   9  1 
ZPIC 5   22   29   7  17  14  42   9  18  
ZPIC 7   103   78   57   43  15  17   3  10  
MEDIC  NA  NA  NA  NA  NA  NA  NA  NA 
TOTAL  213   246   101   123   202   164   32   119  
MIN  10   9  4  4  0  1  0  0 
MAX  103  95   57   43   131   42   9  59  
MEDIAN  25  26   10   14   9  14   2  3 
 
  Continued on next page  
    
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   39 
   
 
 
Figure 47: Benefit Integrity Contractors 2012 and 2013 Workload Statistics (Continued) 
 
Number of Providers  Amount Denied Based on All  Amount Denied Based on  
Added to Prepayment  Prepayment Medical Review   FPS-Related Prepayment 
Contractor   Medical Review    Medical Review 
   2012  2013  2012  2013  2012  2013 
PSC 1  24  30   $851,723   $1,286,813   $48,307   $468,530  
PSC 2  65  52   $22,240,988   $13,421,156   $1,754,136   $1,872,006  
PSC 3  9  4  $5,814,314   $1,398,447   $4,015,316   $1,324,698  
PSC 4  16  7  $6,527,087   $1,847,147   $3,543,363   $705  
ZPIC 1   133  47   $22,230,327   $13,005,518   $2,913,219   $7,438,092  
ZPIC 2   79  38   $4,755,871   $3,498,475   $2,342,503   $2,476,955  
ZPIC 31   5  99   $538,420   $394,074   $0  $50,033  
ZPIC 4   479  117   $19,483,834   $8,817,913   $1,387,257   $67,341  
ZPIC 5   239  115   $10,882,299   $16,526,752   $730,244   $3,219,903  
ZPIC 7   213  121   $42,773,747   $57,402,040   $3,672,548   $4,309,240  
MEDIC  NA  NA  NA  NA  NA  NA 
TOTAL  1,262   630   $136,098,610   $117,598,335   $20,406,893   $21,227,503  
MIN  5  4  $538,420  $394,074   $0   $705  
MAX  479   121  $42,773,747  $57,402,040   $4,015,316   $7,438,092  
MEDIAN  72   50  $8,704,693  $6,158,194   $2,048,320   $1,598,352 
 
             Continued on next page  
 
 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   40 
   
 
Figure 47: Benefit Integrity Contractors 2012 and 2013 Workload Statistics (Continued)  
 
Number of Auto-Deny Edits  Amount Denied Based on All  Amount Denied Based on FPS-Related  
Contractor   Recommended   Auto-Deny Edits  Auto-Deny Edits 
   2012  2013  2012  2013  2012  2013 
PSC 1  4  80   $11,601,484   $10,950,073   $1,538   $19,657  
PSC 2  697  1  $4,519,355   $1,695,724   $0  $0  
PSC 3  0  0  $1,203,457   $535,651   $0  $0  
PSC 4  86  87   $1,519,575   $1,524,352   $0  $0  
ZPIC 1   34  16   $19,592,323   $22,924,720   $1,673,484   $2,069,685  
ZPIC 2   46  10   $47,195   $646,857   $2,156   $607,003  
ZPIC 31   0  4  $133,307   $3,438,102   $0  $0  
ZPIC 4   397  234   $19,026,350   $4,737,405   $493,466   $31,158  
ZPIC 5   1,329  703   $21,091,354   $4,709,872   $147   $1  
ZPIC 7   7,715  2,910   $36,014,951   $28,289,289   $2,664,528   $1,382,846  
MEDIC  NA  NA  NA  NA  NA  NA 
TOTAL  10,308  4,045   $114,749,351   $79,452,045   $4,835,319   $4,110,350  
MIN  0  0  $47,195   $535,651   $0   $0  
MAX  7,715  2,910   $36,014,951   $28,289,289   $2,664,528   $2,069,685  
MEDIAN  66  48   $8,060,420   $4,073,987   $843   $9,829 
 
        Continued on next page  
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   41 
   
 
Figure 47: Benefit Integrity Contractors 2012 and 2013 Workload Statistics  
 
Number of Exclusions   Number of Civil Monetary Penalties 
Contractor   Recommended   Recommended  
   2012  2013  2012  2013 
PSC 1  0  0  0  0 
PSC 2  0  0  0  0 
PSC 3  0  0  0  0 
PSC 4  0  0  0  0 
ZPIC 1   0  0  0  0 
ZPIC 2   0  0  1  2 
ZPIC 31   0  1  0  0 
ZPIC 4   0  0  0  0 
ZPIC 5   0  1  0  1 
ZPIC 7   0  1  0  0 
MEDIC  NA  NA  NA  NA 
TOTAL  0  3  1  3 
MIN  0  0  0  0 
MAX  0  1  1  2 
MEDIAN  0  0  0  0 
 
Source:  OIG analysis of 2012 and 2013 CMS ARTS data and MEDIC workload statistics.  
1 In the beginning of 2012, ZPIC 3 was transitioning into its oversight responsibility.  Therefore, ZPIC 3 has only 8 months of workload  
statistics for 2012. 
 
2  Using the rounded percentages provided in the figure, the median would be 17 percent rather than the actual median of 16 percent.  
 
3 The MEDIC included immediate advisements in its  number of case referrals reported to CMS.  
 
4 The MEDIC reports the potential dollar impact of cases to CMS instead of the amount associated with case referrals which the 
PSCs/ ZPICs report.  These dollar amounts are calculated in  different ways.  The MEDIC reported $973,175,159 as the potential 
dollar impact of cases in 2012 and $5,845,700,034 in 2013.   
 
5  PSCs were not required to report revocations in CMS ARTS. 
 
6 According to CMS, the number of FPS-related payment suspensions recommended should be a subset of the number of payment 
suspensions recommended.  However, because 59 is not a subset of 29, this raises a question about the accuracy of the data reported.    
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   42 
   
APPENDIX C:  RANKING OF CONTRACTORS OVERSIGHT RESPONSIBILITY  
AND WORKLOAD STATISTICS  
 
In this appendix, we provide information on the amounts paid by CMS to each benefit integrity contractor, 
as well as each contractors oversight responsibility and workload results.  To allow for comparisons of 
benefit integrity activities across contractors in 2012 and 2013, we calculated rankings for each workload 
statistic based on the amount of paid claims/expenditures in a contractors jurisdiction.  These rankings are 
based only on the numeric measures reported for the workload statistics. We did not assess the quality of 
work performed by the contractors when determining the rankings.  Appendix D provides more detail on our 
methodology.    
 
We reviewed 11 benefit integrity contractors:  six ZPICs that oversee Parts A and B, Durable Medical 
Equipment (DME), and Home Health and Hospice (HHH) in each of their zones; four PSCs that oversee 
varying service types within their coverage area; and  the MEDIC that oversees Parts C and D nationwide.  
The number of contractors that reported certain workload statistics does not equal 11, as described in 
Figure 48 below. 
  
Figure 48: Some Contractors Are Not Required To Report Certain Workload Statistics  
Number of 
Workload Statistic  Contractors  Reason Contractor Does Not Report  
Reporting  
The MEDIC is excluded; this information is not captured in 
Percentage of Investigations Based on 
10  the MEDICs workload statistics.  
Proactive Leads 
The MEDIC is excluded; FPS applies to Part A and Part B 
Percentage of FPS-Related Investigations  10 
fee-for-service claims, not Parts C and D.  
The MEDIC is excluded; it reports the potential dollar 
Amount Associated with Case Referrals  10 
impact of cases.   
Administrative Actions, Including 
Overpayments, Payment Suspensions,  The MEDIC is excluded; it does not recommend these 
10 
Providers Added to Prepayment Medical  administrative actions.  
Review, and Auto-Deny Edits 
The MEDIC is excluded; it does not recommend this 
administrative action.  In addition, the four PSCs are 
Revocations  6 
excluded;  they were not required to report revocations in 
CMS ARTS. 
 
Source:  OIG analysis of PSC and ZPIC  workload definitions and MEDIC workload statistics.   
 
 
 
 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   43 
   
 
 
   
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
PSC 1 oversees DME in these States    Oversight Responsibility and  Rank  Rank
2012  2013 
and the District of Columbia (DC)  Amount Paid to Contractor   in 2012   in 2013  
Amount of Paid Claims in 
$1,814,944,428   11  $1,555,687,942   11  
Jurisdiction  
Number of Claims in Jurisdiction   11,640,641   10   10,768,163   10  
Amount Paid to Contractor   $4,181,228   11  $4,160,076   11  
 
  WORKLOAD STATISTICS1 
Rank 
 Rank     Rank 
 Rank 

in 2012 
 in 2013  in 2012 
 in 2013 

2012  Per 
 2013  Per  2012  Per  2013 
 Per 

Workload Activity   Workload Activity  
Result   $1 Billion 
 Result   $1 Billion  Result   $1 Billion  Result 
  $1 Billion 

in Paid 
  in Paid   in Paid 
  in Paid 
 
Claims 
 Claims  Claims 
  Claims 
 
 
NInuvmesbteigra otifo  ns  115   1  135  1  NReucmobmemr oefn Rdeevdo  cations  NA  NA  NA  NA 
 
Percentage of  
Number of Revocations 
Investigations Based  13%  1  19%  1  NA  NA  NA  NA 
Implemented 
on Proactive Leads 
  Number of All Payment  
Percentage of FPS-
4%  1  6%  1  Suspensions  0  9  5  1 
Related Investigations  
Recommended  
 
Number of Proactive  Number of FPS-Related 
1  5  1  6 
Projects  Payment Suspensions  0  7  0  7 
Recommended  
 
Number of Immediate 
11  2  5  2 
Advisements  
Number of Auto-Deny 
4  6  80  2 
  Edits Recommended 
Number of Case 
5  1  15  1 
Referrals  
Amount Denied Based 
  $11,601,484   1  $10,950,073   1 
Amount Associated  on All Auto-Deny Edits 
$2,872,548 2  $3,999,452   2 
with Case Referrals  
  Amount Denied Based 
Number of Cases  2  3  6  1  on FPS-Related  $1,538 4  $19,657   4 
Accepted   Auto-Deny Edits 
Number of Requests   
for Information,   57  1  39  2  Number of Providers 
Received   Added to Prepayment   24  2  30  1 
Medical Review 
Number of Requests   
for Information,   65  1  46  1 
Completed  Amount Denied Based 
Amount of     on All Prepayment   $851,723 6  $1,286,813   2 
Medical Review 
Overpayments   $6,003,840 2  $4,289,702   2 
Referred  
  Amount Denied Based 
Amount of   on FPS-Related 
Overpayments   $1,966,172   1  $926,017   2  Prepayment Medical   $48,307   8  $468,530   1 
Recovered   Review 
 
1 For these data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable .  To determine the individual workload statistic ranks, we calculated the 
 
contractors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   44 
   
 
   
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
PSC 2 oversees Parts  A   Oversight Responsibility and  Rank  Rank 
2012   
and B in these States   Amount Paid to Contractor   in 2012   in 2013  
Amount of Paid Claims in 
$32,755,864,765   7  $31,590,344,161   7 
Jurisdiction  
Number of Claims in Jurisdiction   98,661,865   5  96,386,017   5 
Amount Paid to Contractor   $8,139,871   7  $9,031,506   7 
 
  WORKLOAD STATISTICS1 
Rank  Rank     Rank 
 Rank 
 
in 2012  in 2013  in 2012 
 in 2013 

2012  Per  2013  Per  2012  Per  2013 
 Per 

Workload Activity   Workload Activity  
Result   $1 Billion  Result   $1 Billion  Result   $1 Billion  Result 
  $1 Billion 

in Paid   in Paid   in Paid 
  in Paid 
 
Claims  Claims  Claims 
  Claims 
 
 
Number of   Number of Revocations 
348 10  259   8  NA  NA  NA  NA 
Investigations  Recommended  
 
Percentage of   Number of Revocations 
Investigations Based  11%  4  18%  4  Implemented  NA  NA  NA  NA 
on Proactive Leads 
 
Number of All Payment  
Percentage of FPS-
5%  8  14%  8  Suspensions  3  8  11  7 
Related Investigations  
Recommended  
 
Number of Proactive 
43  3  88  2 
Projects  Number of FPS-Related 
Payment Suspensions  0  7  4  5 
 
Number of Immediate  Recommended  
118 4  45  5 
Advisements  
 
Number of Auto-Deny 
Number of Case  697 2  1  9 
20  7  18  6  Edits Recommended 
Referrals  
 
Amount Denied Based 
Amount Associated  $4,519,355   6  $1,695,724   8 
$25,333,789 5  $20,554,539   5  on All Auto-Deny Edits 
with Case Referrals  
 
Number of Cases  Amount Denied Based 
Accepted   11  8  15  6  on FPS-Related  $0  7  $0  6 
Auto-Deny Edits 
 
Number of Requests 
for Information,   244 8  273   9  Number of Providers 
Received   Added to Prepayment   65  7  52  5 
Number of Requests    Medical Review 
for Information,   256   9  271   9 
Completed  Amount Denied Based 
  on All Prepayment   $22,240,988   2  $13,421,156   3 
Amount of   Medical Review 
Overpayments   $36,132,797 4  $33,496,806   6 
Referred  
Amount Denied Based 
Amount of     on FPS-Related  $1,754,136   6  $1,872,006   5 
Prepayment Medical  
Overpayments   $10,443,363   4  $6,729,556   6 
Review 
Recovered  
 
 
1 For  these data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
contractors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   45 
   
 
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
PSC 3 oversees HHH in these States and   Oversight Responsibility and  Rank  Rank in
 
  2012 
 2013 

DC and Parts A and B in these States    Amount Paid to Contractor   in 2012 
  2013 

and DC with the    
Amount of Paid Claims in 
exception of    $29,750,869,643   8  $29,554,086,368   8 
  Jurisdiction  
NJ, NY, 
and PA    Number of Claims in Jurisdiction   85,729,052   7  86,658,779   7 
 
  Amount Paid to Contractor   $7,396,392   8  $8,162,781   9 
 
 
WORKLOAD STATISTICS1  
 
 
Rank  Rank  Rank  Rank 
in 2012 
 in 2013 
 in 2012 
 in 2013 

2012  Per  2013  Per 
 2012  Per  2013  Per

Workload Activity   Workload Activity  
Result   $1 Billion  Result   $1 Billion  Result   $1 Billion  Result   $1 Billion 
in Paid   in Paid   in Paid   in Paid  
Claims  Claims  Claims   Claims  
 
Number of   Number of  
Investigations  339 	 7  313  5  R
evocations  NA  NA  NA  NA 
Recommended  
Percentage of    
Number of  
Investigations Based  2%  7  7%  7 

Revocations  NA  NA  NA  NA 

on Proactive Leads 
Implemented 
 
Percentage of   Number of All  
FPS-Related  10%  5  13%  7  P
ayment  
Investigations  Suspensions  5  6  	4  8  

  Recommended  
Number of Proactive 
Projects  11  6  13  8 
 Number of  
FPS-Related Payment  
0  7  0  7 

  Suspensions 
Number of Immediate 
55  	8  8  9  R
ecommended  
Advisements  
 
Number of Case  Number of Auto-Deny 
10 	 9  12  8
 0  9  0  10  

Referrals   Edits Recommended 
 
Amount Denied 
Amount Associated 
$3,349,368   8  $4,683,687   7 
 Based on All   $1,203,457   8  $535,651   9 

with Case Referrals  
Auto-Deny Edits 
  Amount Denied 
NAuccmebpeter do  f Cases  4  9  8  9 
 BFPaSse-Rde olant ed  $0  7  $0  6 

Auto-Deny Edits 
Number of Requests   
for Information,   380  6  342  7  

Number of Providers 
Received  
Added to Prepayment   9  9 	 4  10 

Number of Requests    Medical Review 
for Information,   366   6  357   7 

Completed  Amount Denied 
Based on All  
  $5,814,314 7  $1,398,447   9  

Amount of   Prepayment Medical  
Overpayments   $11,376,694   8  $12,178,748   10 
 Review 
Referred   Amount Denied 
Based on 
Amount of    
FPS-Related  $4,015,316   3  $1,324,698   7

Overpayments   $5,615,388   7  $2,642,464   8 

Prepayment Medical  
Recovered  
Review 
 
1 For these data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
contractors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                        46  
   
 
 
 
 
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
  Rank  Rank
PSC 4 oversees Parts A and B in this State 	  Oversight Responsibility and 
2012  in  2013  in
Amount Paid to Contractor  
2012  2013 
Amount of Paid Claims in 
$13,731,774,602 	   10  $13,258,799,990    10  
Jurisdiction  
Number of Claims in Jurisdiction   42,262,387   9  41,503,657   9 
Amount Paid to Contractor   $4,328,598   10  $5,216,489   10  
 
WORKLOAD STATISTICS1  
 
Rank    Rank 
Rank in  Rank in
in 2012  in 2012 
2013 Per   2013 Per  
2012  Per  2013  2012  Per  2013 
Workload Activity   $1 Billion  Workload Activity   $1 Billion 
Result   $1 Billion  Result   Result   $1 Billion  Result  
in Paid   in Paid 
in Paid   in Paid  
Claims  Claims 
Claims  Claims  
 
Number of  
226 5  177   4  Number of Revocations 
Investigations  NA  NA  NA  NA 
Recommended  
 
Percentage of  
Investigations Based  13%  2  5%  6  Number of Revocations 
on Proactive Leads  Implemented  NA  NA  NA  NA 
 
Percentage of FPS- Number of All Payment  
3%  6  19%  3 
Related Investigations   Suspensions  0  9  1  10 
Recommended  
 
Number of Proactive 
Projects  0  11  9  5  Number of FPS-Related 
Payment Suspensions  0  7  0  7 
  Recommended  
Number of Immediate 
28  7  3  10 
Advisements  
Number of Auto-Deny 
  86  5  87  5 
Number of Case  Edits Recommended 
1  10  2  10 
Referrals  
Awmitho uCnats Ae sRseofceiraratelsd    $28,667   10  $0  10    Aonm Aolul nAtu Dtoe-nDieedn yB Easdeitds   $1,519,575   7  $1,524,352   5 
 
Number of Cases 
0  11  1  11 	 Amount Denied Based 
Accepted  
on FPS-Related  $0  7  $0  6 
Number of Requests    Auto-Deny Edits 
for Information,   126 7  196   4 
Received   Number of Providers 
  Added to Prepayment   16  8  7  9 
Number of Requests 
Medical Review 
for Information,   130   7  191   4 
Completed  Amount Denied Based 
Amount of     on All Prepayment   $6,527,087   5  $1,847,147   7 
Overpayments   $9,950,243   6  $26,595,400   3  Medical Review 
Referred  
Amount Denied Based 
 
Amount of   on FPS-Related 
$3,543,363   1  $705  10 
Overpayments   $2,037,924   8  $3,400,024   5  Prepayment Medical  
Recovered   Review 
1 For these  data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
 
contractors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   47 
   
 
 
 
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
  Oversight Responsibility and Amount  Rank  Rank 
ZPIC 1   Paid to Contractor  2012  in 2012   2013  in 2013  
oversees 
Part A, Part B,  
Amount of Paid Claims in Jurisdiction   $35,863,542,103   6  $35,330,473,103   5 
DME, and  
HHH in these 
States.2    Number of Claims in Jurisdiction   93,590,619   6  91,712,988   6 
Amount Paid to Contractor   $10,558,369   6  $11,649,892   5 
 
2 ZPIC 1 also oversees the U.S. territories of Northern Mariana Islands, American Samoa, and Guam. 
 
WORKLOAD STATISTICS1  
 
Rank  Rank in    Rank 
 Rank in 

in 2012  2013   in 2012 
 2013  

2012  Per  2013  Per  2012  Per  2013 
 Per 

Workload Activity   Workload Activity  
Result   $1 Billion  Result   $1 Billion  Result   $1 Billion  Result 
  $1 Billion 

in Paid   in Paid   in Paid 
  in Paid 
 
Claims  Claims  Claims 
  Claims 

 
Number of   Number of Revocations 
609 4  290   7  27  3  12  5 
Investigations  Recommended  
 
Percentage of  
Number of Revocations 
Investigations Based  3%  8  4%  9  14  2  11  3 
Implemented 
on Proactive Leads 
 
Percentage of FPS- Number of All Payment  
Related Investigations   13%  4  27%  5  Suspensions  4  7  3  9 
Recommended  
 
Number of Proactive 
Projects  94  1  70  3  Number of FPS-Related 
Payment Suspensions  4  4  0  7 
Number of Immediate    Recommended  
34  10  10  8 
Advisements  
  Number of Auto-Deny 
Number of Case  34  8  16  6 
18  8  14  9  Edits Recommended 
Referrals  
 
Amount Associated  Amount Denied Based 
$16,782,312   7  $7,355,505   6  $19,592,323   3  $22,924,720   3 
with Case Referrals   on All Auto-Deny Edits 
 
Number of Cases  Amount Denied Based 
16  6  11  8 
Accepted   on FPS-Related  $1,673,484   2  $2,069,685   1 
Auto-Deny Edits 
Number of Requests   
for Information,   831 3  463   6 
Number of Providers 
Received  
Added to Prepayment   133   5  47  7 
 
Number of Requests  Medical Review 
for Information,   872   2  472   6 
Completed  Amount Denied Based 
Amount of     on All Prepayment   $22,230,327   3  $13,005,518   4 
Overpayments   $13,858,237   7  $16,892,314   9  Medical Review 
Referred   
Amount Denied Based 
 
Amount of   on FPS-Related 
$2,913,219   4  $7,438,092   2 
Overpayments   $2,825,043   9  $2,785,678   9  Prepayment Medical  
Recovered    Review 
 
1 For these  data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
contracto rs workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   48 
   
 
 
   
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
  Oversight Responsibility and Amount  Rank  Rank

2012 
 2013 

Paid to Contractor  in 2012 
  in 2013 
 
Amount of Paid Claims in Jurisdiction   $37,668,706,944    4  $37,499,149,073    4 
ZPIC 2 oversees 
Number of Claims in Jurisdiction   119,299,942   3  118,097,845   3 
Part A, Part B, 
DME, and HHH 
in these States.    Amount Paid to Contractor   $11,086,474   5  $10,760,812   6 
 
WORKLOAD STATISTICS1  
 
Rank  Rank in    Rank  Rank 
 
in 2012   2013  
 in 
 in 2013 

2012  Per  2013  Per 
 2012  2012 Per   2013   Per

Workload Activity   Workload Activity  
Result   $1 Billion  Result   $1 Billion  Result   $1 Billion  Result   $1 Billion 
in Paid   in Paid   in Paid   in Paid  
Claims  Claims  Claims  Claims  
  Number of 
 
Number of  
571  6  239   11  Revocations 
 10  5  9  6  

Investigations 
Recommended  
Percentage of     Number of  
Investigations Based  12%  5  5%  8 
 Revocations  4  6  8  5 

on Proactive Leads  Implemented 
Percentage of     Number of  All 
 
FPS-Related  18%  3  62%  2  Payment 
 
13  3  28  2

Investigations  Suspensions 

  Recommended 
 
Number of Proactive  32  4  33  4 
 Number of  
Projects  FPS-Related Payment  
1  6  27  2 

Suspensions 
 
Number of Immediate  Recommended  
95  5  43  6  

Advisements  
Number of Auto-Deny 
46  7  10  7

  Edits Recommended 
Number of Case 
94  2  28  5 

Referrals  
Amount Denied 
  Based on All   $47,195   10  $646,857   10 

Amount Associated  $55,887,049   3  $62,408,253   3 
 Auto-Deny Edits 
with Case Referrals  
Amount Denied 

NAuccmebpeter do  f Cases  50  2  25  4 
   BFPaSse-Rde olant e
 d  $2,156   5  $607,003   3

Auto-Deny Edits 
Number of Requests   
for Information,   253  9  360   8  N
umber of Providers 
Received   Added to Prepayment   79  6  38  8 

Number of Requests    Medical Review 
for Information,   315   8  324   8 

Amount Denied 

Completed 
Based on All 
 
Amount of     Prepayment Medical   $4,755,871   9  $3,498,475   8

Overpayments   $12,602,608   9  $26,341,201   7  Review 
Referred   Amount Denied 
  Based on 
Amount of  
FPS-Related  $2,342,503   5  $2,476,955   4

Overpayments   $8,654,999   6  $6,397,790   7 

Prepayment Medical  
Recovered  
Review 
 
1 For t hese data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
contractors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   49 
   
 
 
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
  Oversight Responsibility and Amount 
 2012  Rank 
 2013  Rank 

Paid to Contractor 
 in 2012 
  in 2013 
 
Amount of Paid Claims in Jurisdiction   $65,082,042,811   2  $63,122,742,569   2 
Number of Claims in Jurisdiction   207,536,737   1  202,903,810   2 
ZPIC 3 oversees Part A, 
Part B, DME, and HHH 
Amount Paid to Contractor   $5,808,220   9  $8,769,293   8 
in these States.    
 
WORKLOAD STATISTICS1  
 
Rank  Rank in    Rank 
 Rank 

in 2012   2013   in 2012 
  in 2013 

2012   Per  2013   Per  2012   Per  2013  
 Per 

Workload Activity   Workload Activity  
Result   $1 Billion  Result   $1 Billion  Result   $1 Billion  Result 
  $1 Billion 

in Paid   in Paid   in Paid 
  in Paid 
 
Claims2   Claims  Claims2
   Claims 
 
 
Number of   Number of Revocations 
710 8  875   3  14  6  23  4 
Investigations  Recommended  
 
Percentage of  
Number of Revocations 
Investigations Based  1%  9  1%  10  11  4  4  6 
Implemented 
on Proactive Leads 
  Number of All Payment  
Percentage of FPS- 3%  10  3%  10  Suspensions  17  4  29  6 
Related Investigations   Recommended  
 
Number of Proactive  Number of FPS-Related 
Projects  4  9  28  7  Payment Suspensions  6  5  59  1 
Recommended  
 
Number of Immediate 
164 6  123   4 
Advisements   Number of Auto-Deny 
0  9  4  8 
Edits Recommended 
 
Number of Case 
2  11  6  11 
Referrals  
Amount Denied Based 
  $133,307   9  $3,438,102   7 
Amount Associated  on All Auto-Deny Edits 
$3,474,596   9  $779,376   9 
with Case Referrals  
  Amount Denied Based 
Number of Cases  5  10  5  10  on FPS-Related  $0  7  $0  6 
Accepted   Auto-Deny Edits 
Number of Requests   
for Information,   274 10  417   10  Number of Providers 
Received   Added to Prepayment   5  10  99  6 
Number of Requests    Medical Review 
for Information,   243   10  429   10 
Completed  Amount Denied Based 
Amount of     on All Prepayment   $538,420   10  $394,074   10 
Overpayments   $14,011,756   10  $68,909,038   5  Medical Review 
Referred  
Amount Denied Based 
Amount of     on FPS-Related 
$0  10  $50,033   9 
Overpayments   $2,402,562   10  $2,091,536   10  Prepayment Medical  
Recovered   Review 
 
 
1 For these data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
 
contractors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
 
2 In the beginning of  2012, ZPIC 3 was transitioning into its oversight responsibility. Therefore, ZPIC 3 has only 8 months of workload statistics for 2012.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                        50  
 
   
 
 
 
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
  ZPIC 4 oversees  Oversight Responsibility and Amount  2012 
 Rank  2013 
 Rank
Paid to Contractor  in 2012 
  in 2013 
 
Part A, Part B, 
DME, and HHH in  Amount of Paid Claims in 
these States.    $36,191,979,987   5  $34,633,753,305   6 
Jurisdiction  
Number of Claims in Jurisdiction   100,784,808   4  97,382,115   4 
Amount Paid to Contractor   $12,244,080   4  $13,116,535   4 
 
WORKLOAD STATISTICS1  
 
Rank 
 Rank 
    Rank  Rank 
 
in 2012 
 in 2013 
  in 2012 
 in 2013 

2012   Per 
 2013  
 Per 
 2012   Per  2013   Per 

Workload Activity   Workload Activity  
Result   $1 Billion  Result 
  $1 Billion  Result   $1 Billion  Result   $1 Billion 

in Paid   in Paid   in Paid 
  in Paid  
Claims  Claims  Claims   Claims  
  Number of  
Number of  
385  9  
348 
  6  Revocations  37  2  95  2  

Investigations 
Recommended  
Percentage of    
Number of  
Investigations 
11%  6 
 20%  3 
 Revocations  8  3  40  2 

Based on Proactive 
Implemented 
Leads  
Percentage of FPS-   Number of All  
Payment  
Related  22%  2  
14%  9  
 131 1  24  3  

Suspensions 
Investigations 
Recommended  
 
Number of Proactive  Number of  
1  10 
 5 
 11 

Projects  FPS-Related 
Payment   9  1  1  6 

Number of     Suspensions 
Immediate  0  11  
0  11  Rec
ommended  
Advisements   Number of  
  Auto-Deny Edits  397 4  234   4  

Number of Case  87  3 
 99 
 2 
 Recommended  
Referrals  
Amount Denied 
  Based on All   $19,026,350   4  $4,737,405   4 

Amount Associated 
$174,383,335   1 
 $186,099,736   1 
 Auto-Deny Edits 
with Case Referrals  
Amount Denied 
 
NAuccmebpeter do  f Cases  32  4 
 33 
 3 
 BFPaSse-Rde olant ed  $493,466   3  $31,158   5 

Auto-Deny Edits 
Number of Requests    Number of Providers 
for Information,   876  2  
523 
  3  Ad
ded to  
479   1  117   3 

Received   Prepayment Medical  
Review 
Number of Requests   
for Information,   846   3 
 529 
  3 
 Amount Denied 
Completed  Based on All   $19,483,834   4  $8,817,913   6 

Prepayment Medical  
Amount of     Review 
Overpayments   $29,269,446   5 
 $20,891,102   8 

Referred   Amount Denied 
Based on 
Amount of    
FPS-Related  $1,387,257   7  $67,341   8 

Overpayments   $16,948,585   3 
 $19,904,797   3 

Prepayment Medical  
Recovered  
Review 
1 For these d ata, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
contra ctors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   51 
   
 
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
  
 ZPIC  5 oversees Part A, Part B,    Oversight Responsibility  Amount   2012  Rank  2013  Rank
DME, and HHH in these States.    Paid to Contractor  in 2012   in 2013  
 
Amount of Paid Claims in 
  $63,556,854,926   3  $62,074,919,758   3 
Jurisdiction  
 
Number of Claims in Jurisdiction   205,241,991   2  203,503,883   1 
 
 
Amount Paid to Contractor   $16,083,657   2  $16,740,734   2 
 
WORKLOAD STATISTICS1  
 
Rank  Rank     Rank
  
Rank in  
in 2012  in 2013  in 2013 

2012 Per  
2012   Per  2013   Per  2012   2013   Per 

Workload Activity   Workload Activity   $1 Billion 
Result   $1 Billion  Result   $1 Billion  Result   Result   $1 Billion 

in Paid  
in Paid   in Paid   in Paid 
 
Claims  
Claims  Claims  Claims 
 
 
Number of   Number of Revocations 
1,881  3  442   9  22  4  29  3 
Investigations  Recommended  
 
Percentage of  
Number of Revocations 
Investigations Based  <1%  10  23%  5  7  5  17  4 
Implemented 
on Proactive Leads 
 
Percentage of FPS- 9%  9  46%  6  Number of All Payment  
Related Investigations   Suspensions  14  5  42  4 
Recommended  
 
Number of Proactive 
5  8  23  9 
Projects  Number of FPS-Related 
Payment Suspensions  9  2  18  4 
 
Recommended  
Number of Immediate 
233 3  138   3 
Advisements  
Number of Auto-Deny 
1,329  3  703   3 
  Edits Recommended 
Number of Case 
72  5  35  7 
Referrals  
  Amount Denied Based  $21,091,354   5  $4,709,872   6 
Amount Associated  on All Auto-Deny Edits 
$52,067,827   4  $3,041,859   8 
with Case Referrals  
  Amount Denied Based 
Number of Cases 
24  7  32  5  on FPS-Related  $147  6  $1  6 
Accepted  
Auto-Deny Edits 
Number of Requests   
for Information,   1,088  4  856   5 
Number of Providers 
Received  
Added to Prepayment   239   4  115   4 
Number of Requests    Medical Review 
for Information,   1,126  5  854   5 
Completed 
Amount Denied Based 
Amount of     on All Prepayment   $10,882,299   8  $16,526,752   5 
Overpayments   $151,368,715   3  $104,837,518   4  Medical Review 
Referred  
Amount Denied Based 
Amount of     on FPS-Related 
Overpayments   $32,004,481   2  $41,156,043   1  Prepayment Medical   $730,244   9  $3,219,903   6 
Recovered   Review 
1 For these  data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
contractors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                       52  
   
 
 
   
 
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
Oversight Responsibility and Amount  Rank  Rank 
  2012  2013 
Paid to Contractor  in 2012   in 2013  
ZPIC 7 oversees 
Part A, Part B,  Amount of Paid Claims in Jurisdiction   $26,726,385,968   9  $25,832,530,936   9 
DME, and HHH 
in these States.2    
Number of Claims in Jurisdiction   82,608,397   8  80,367,263   8 
Amount Paid to Contractor   $24,196,730   1  $23,249,314   1 
 
2 ZPIC 7 also oversees the U.S. Virgin Islands. 
WORKLOAD STATISTICS1  
 
Rank  Rank     Rank 
 Rank 
 
in 2012  in 2013  in 2012 
 in 2013 

2012   Per  2013   Per  2012   Per  2013  
 Per 

Workload Activity   Workload Activity  
Result   $1 Billion  Result   $1 Billion  Result   $1 Billion  Result 
  $1 Billion 

in Paid   in Paid   in Paid 
  in Paid 
 
Claims  Claims  Claims 
  Claims 
 
 
NInuvmesbteigra otifo  ns  1,119  2  816   2  NReucmobmemr oefn Rdeevdo  cations  103 1  78  1 
 
Percentage of  
Investigations Based  23%  3  21%  2  Number of Revocations 
57  1  43  1 
on Proactive Leads  Implemented 
 
Percentage of FPS-
5%  7  31%  4  N	 umber of All Payment  
Related Investigations  
Suspensions  15  2  17  5 
Recommended  
 
Number of Proactive 
50  2  101   1 
Projects 
Number of FPS-Related 
  Payment Suspensions  3  3  10  3 
Number of Immediate 
213 1  94  1  Recommended  
Advisements  
 
NReufmerbrearls o  f Case  30  6  26  4  NEduimtsb Rere coof mAumtoen-Ddeendy   7,715  1  2,910  1 
 
Amount Denied Based 
Amount Associated  $36,014,951   2  $28,289,289   2 
$15,130,018   6  $41,660,048   4  on All Auto-Deny Edits 
with Case Referrals  
  Amount Denied Based 
Number of Cases 
14  5  12  7  on FPS-Related  $2,664,528   1  $1,382,846   2 
Accepted  
Auto-Deny Edits 
Number of Requests   
for Information,   443 5  689   1  Number of Providers 
Received   Added to Prepayment   213   3  121   2 
Number of Requests    Medical Review 
for Information,   487   4  692   2 
Completed  Amount Denied Based 
Amount of     on All Prepayment   $42,773,747   1  $57,402,040   1 
Overpayments   $90,861,223   1  $90,883,843   1  Medical Review 
Referred  
Amount Denied Based 
Amount of     on FPS-Related 
$3,672,548   2  $4,309,240   3 
Overpayments   $7,177,789   5  $10,660,495   4  Prepayment Medical  
Recovered   Review 
1 For these data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
contractor s workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work perfo rmed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   53 
   
   
 
 
 
OVERSIGHT RESPONSIBILITY AND AMOUNT PAID1  
 
  Oversight Responsibility and Amount  2012  Rank 2013  Rank
Paid to Contractor  in 2012   in 2013  
Amount of Part C and D Expenditures 
$193,327,469,728   1  $205,908,214,464   1 
in Jurisdiction  
The MEDIC 
Number of Claims in Jurisdiction   N/A  N/A  N/A  N/A 
oversees 
Part C and 
Part D  Amount Paid to Contractor	   $12,333,088   3  $13,559,830   3 
nationwide.   
 
WORKLOAD STATISTICS1  
 
Rank  Rank     Rank  Rank  
in 2012   in 2013   in 2012   in 2013  
2012   2013  2012   2013  
Workload Activity   Per  Per  Workload Activity   Per  Per 
Result   Result  Result   Result  
$1 Billion in   $1 Billion in   $1 Billion in   $1 Billion in  
Expenditures  Expenditures  Expenditures  Expenditures 
  Number of  
Number of  
1,894  11  1,349  10  Revocations  NA  NA  NA  NA 
Investigations 
Recommended  
 
Percentage of 	  Number of  
Investigations Based  NA  NA  NA  NA  Revocations  NA  NA  NA  NA 
on Proactive Leads  Implemented  
Percentage of     Number of All  
FPS-Related  NA  NA  NA  NA  Payment  NA  NA  NA  NA 
Investigations  Suspensions 
Recommended  
 
Number of Proactive 
18  7  49  10  Number of  
Projects 
FPS-Related Payment  
NA  NA  NA  NA 
  Suspensions 
Number of Immediate  202 9  171   7  Recommended  
Advisements  
  Number of Auto-Deny 
NA  NA  NA  NA 
Number of Case  Edits Recommended 
429   4  384   3 
Referrals  
Amount Denied 
 
Amount Associated  Based on All   NA  NA  NA  NA 
with Case Referrals   NA  NA  NA  NA  Auto-Deny Edits 
  Amount Denied 
Number of Cases 
274   1  237   2 	 Based on 
Accepted   NA  NA  NA  NA 
FPS-Related 
Number of Requests    Auto-Deny Edits 
for Information,   470 11  489   11 
Number of Providers 
Received  
Added to Prepayment   NA  NA  NA  NA 
Number of Requests    Medical Review 
for Information,   473   11  464   11 
Amount Denied 
Completed 
Based on All  
NA  NA  NA  NA 
Amount of     Prepayment Medical  
Overpayments   NA  NA  NA  NA  Review 
Referred   Amount Denied 
  Based on 
Amount of   FPS-Related  NA  NA  NA  NA 
Overpayments   NA  NA  NA  NA  Prepayment Medical  
Recovered   Review 
1 For these data, 1  is the highest rank.   The rankings are based on 11 contractors, where applicable.  To determine the individual workload statistic ranks, we calculated the 
contractors workload result per $1 billion  in paid claims.  The rankings are based only on the numeric measures reported for the workload statistics; we did not assess the quality of  
work performed by the contractors when determining the rankings.  
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                        54  
   
APPENDIX D:  METHODOLOGY  
 
Data Collection and Analysis 
The PSC, ZPIC, and MEDIC statements of work establish the fundamental activities that CMS may award to 
them through individual task orders.  For PSCs and ZPICs, one type of task order awarded is the benefit 
integrity fee-for-service task order.  This task order addresses benefit integrity work for Medicare Part A, Part 
B, DME, and HHH. The MEDIC task order addresses benefit integrity work for Medicare Part C and Part D. 
PSCs and ZPICs are required to report to CMSusing CMS ARTSmonthly workload statistics related to 
their benefit integrity task orders.   For the four PSCs and six ZPICs, we obtained the workload statistics for 
their benefit integrity fee-for-service task orders for calendar years 2012 and 2013.  In the beginning of 2012, 
ZPIC 3 was transitioning into its oversight responsibility; therefore, ZPIC 3 has only 8 months of workload 
statistics for 2012. The workload statistics include, but are not limited to, the number of investigations and 
case referrals resulting from external and proactive leads; immediate advisements; requests for information 
received; and the amounts of overpayments referred to and recovered by MACs.  We extracted the data from 
CMS ARTS in March and April 2015.   
The MEDIC is required to report to CMS monthly workload statistics related to its benefit integrity task order.  
CMS provided OIG with the MEDICs monthly workload statistics for calendar years 2012 and 2013.   
For each contractor, we summarized for each year: 
	   the number of investigations started;  
	   the number and percentage of investigations started based on external and proactive leads 
(PSCs and ZPICs only);  
	   the number of investigations that were based on leads from the Fraud Prevention System 
(PSCs and ZPICs only); 
	   the number of proactive data-analysis projects started;  
	   the number of immediate advisements submitted to OIG;  
	   the number of cases referred to law enforcement; 
	   the number of case referrals resulting from investigations based on external and proactive 
leads (PSCs and ZPICs only); 
	   the dollar amount associated with cases referred to law enforcement (PSCs and ZPICs only); 
	   the potential dollar impact of MEDIC case referrals; and 
	   the number of requests for information, received and completed.  
For select workload statistics, we calculated the percentage difference across years; we also calculated the 
percentage of the total that each contractor represented for that particular statistic.  
For the PSCs and ZPICs only, we summarized the number of administrative actions recommended 
including revocations, exclusions, civil monetary penalties, payment suspensions, prepayment medical 
review, and auto-deny edits.1   Also, we summarized the amounts denied based on all prepayment medical  
   
 
1 The MEDIC is not required to recommend administrative actions.  
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review and auto-deny edits as well as those denied based on FPS-related prepayment review and 
auto-deny edits. In addition, we calculated the amounts of overpayments referred for recovery based on 
investigations and case referrals and calculated the amounts of overpayments recovered based on 
investigations and case referrals.  We summarized and compared these totals across years and for 
individual PSCs and ZPICs.    
To enable meaningful comparisons between contractors, we obtained from CMS information regarding 
each benefit integrity contractors oversight responsibility in 2012 and 2013.  Specifically, for the PSCs and 
ZPICs, we obtained the number of claims processed and the total amount paid for those claims in their 
respective jurisdictions. For the MEDIC, we obtained Part C and Part D expenditures, i.e., the amounts 
CMS paid to Part C and Part D plan sponsors. We also obtained the amounts paid to each PSC, ZPIC, 
and the MEDIC for work performed in 2012 and 2013. We compared the level of certain benefit integrity 
activities to the contractors oversight responsibilities.  We compared activity levels per $1 billion in paid 
claims or expenditure amounts and per $1 million in contract payment amounts. 
Ranking of Contractors 
We ranked the 11 contractors by the size of their respective oversight responsibilities, i.e., the amounts of 
paid claims or expenditures, and the numbers of claims.  We also ranked the contractors by the respective 
amounts paid to them. To do this, we arrayed the raw data from highest to lowest and then assigned each 
statistic a rank. For these data, 1 represents the highest amount for this statistic and 11 represents the 
lowest amount. However, 10 represents the lowest amount for number of claims because we did not 
include the MEDIC in this ranking. 
We also assigned a rank for each contractors workload statistics in 2012 and 2013.  To allow for 
comparisons of workload statistics across contractors, we calculated the contractors workload result per 
$1 billion in claim oversight responsibility.  We then arrayed the data from highest to lowest and assigned 
each workload statistic a rank. For these data, 1 is the highest rank; the lowest rank depends on the 
number of contractors that reported the data.  In those instances where contractors had identical workload 
results per $1 billion in paid claims, we assigned the same rank for that statistic and omitted the next rank.  
The rankings are based only on the numeric measures reported for the workload statistics.  We did not 
assess the quality of work performed by the contractors when determining the rankings.   
 
 
   
  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   56 
   
APPENDIX E:  PREVIOUS OIG REPORTS ON BENEFIT INTEGRITY  
CONTRACTORS  
 
 
All of these reports are available on OIGs website at oig.hhs.gov.   
 
   MEDIC Benefit Integrity Activities in Medicare Parts C and D, OEI-03-11-00310, January 2013.  
 
   Zone Program Integrity Contractors Data Issues Hinder Effective Oversight, OEI-03-09-00520, 
November 2011. 
 
   Medicare Drug Integrity Contractors Identification of Potential Part D Fraud and Abuse, 
OEI-03-08-00420, October 2009. 
 
   Medicares Program Safeguard Contractors:  Activities to Detect and Deter Fraud and Abuse, 
OEI-03-06-00010, July 2007. 
 
   Fiscal Intermediary Fraud Units, OEI-03-97-00350, November 1998. 
 
   Carrier Fraud Units, OEI-05-94-00470, November 1996.  
 
 
   
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APPENDIX F:  AGENCY COMMENTS  
 
 
 
   
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  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   59 
   
ACKNOWLEDGMENTS  
 
 
This report was prepared under the direction of Linda Ragone, Regional Inspector General for Evaluation 

and Inspections in the Philadelphia regional office, and Tara Bernabe, Deputy Regional Inspector General.  

Tara Bernabe served as the team leader for this study.  Other Office of Evaluation and Inspections staff from 

the Philadelphia regional office who contributed to the study include Robert A. Vito and Nancy J. Molyneaux. 

Central office staff who provided support include Lucia Fort, Scott Manley, Christine Moritz, and 

Joanne Legomsky.    

  Medicare Benefit Integrity Contractors Activities in 2012 and 2013:  A Data Compendium (OEI-03-13-00620)                                   60