Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
Z   P I
ONE  ROGRAM  NTEGRITY 
 
C  D I
ONTRACTORS   ATA  SSUES   
 
H E O  
INDER  FFECTIVE  VERSIGHT
 
 
 
 
 
 
 
Daniel R. Levinson  
Inspector General 
 
November 2011 
OEI-03-09-00520    
   
 E X E C U T I V E   S U M M A R Y  
OBJECTIVES
 
1.  To perform an early assessment of the Centers for Medicare & 
Medicaid Services (CMS) oversight of the Zone Program Integrity 
Contractors (ZPIC).    
2.  To describe the extent to which ZPICs performed program 
integrity activities, including investigations, case referrals, 
responses to requests for information, and administrative actions. 
3.  To determine the extent to which CMS used program integrity 
workload statistics in ZPIC performance evaluations.   
4.  To describe any barriers encountered by ZPICs in performing their 
Medicare program integrity activities. 
BACKGROUND 
This study is part of the Office of Inspector Generals (OIG) body of work 
examining the identification and investigation of fraud, waste, and 
abuse by Medicare program integrity contractors.  OIG has identified 
oversight of CMS program and benefit integrity contractors as a top 
management challenge for the Department of Health and Human 
Services.  Previous OIG studies found vulnerabilities in these 
contractors efforts to combat fraud and abuse.  This is the first study 
examining ZPICs program integrity activities.     
CMS is replacing Program Safeguard Contractors (PSC) with ZPICs, 
which will perform Parts A and B program integrity work in seven 
newly established geographical zones.  CMS awarded the first two ZPIC 
contracts for Zones 4 and 7 on September 30, 2008, and both ZPICs 
were operational as of February 1, 2009.  As of September 2011, CMS 
had awarded the remaining five ZPIC contracts and five of the seven 
ZPICs were operational.      
ZPICs are required to report monthly workload statistics related to 
their program integrity activities, including investigations, case 
referrals, requests for information, and administrative actions.  CMS 
tracks and analyzes these statistics using an online system called the 
CMS Analysis, Reporting, and Tracking System (CMS ARTS).   
Our study was limited to the ZPICs in Zones 4 and 7 because they were 
the only ZPICs that had completed a full contract year at the time of our 
review.  Our study reviewed ZPICs activities for the period  
February 1 through October 31, 2009.  We collected and reviewed 
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E X E C U T I V E   S U M M A R Y  
ZPICs workload data in CMS ARTS and contacted CMS staff to help 
resolve discrepancies in the workload data.  Additionally, we reviewed 
ZPICs performance evaluations and surveyed the ZPICs to identify any 
barriers they encountered in performing their program integrity 
activities.   
FINDINGS   
Workload data used by CMS to oversee ZPICs were not accurate or 
uniform.  There were inaccuracies and a lack of uniformity in ZPIC data 
as a result of system issues in CMS ARTS, ZPIC reporting errors, 
ZPICs interpretations of workload definitions, and inconsistencies in 
requests for information reports.   
A visual review of ZPICs workload data revealed a CMS ARTS system 
error that resulted in incorrect data relating to ZPICs investigations 
and cases.  Additionally, we found that ZPICs interpretations of 
workload definitions led to a lack of uniformity in workload data.  
Specifically, the ZPICs counted and reported their new investigations 
differently in their workload statistics in CMS ARTS.  This lack of 
uniformity could be the reason that one ZPIC reported seven times more 
investigations originating from external sources (e.g., complaints) than 
the other.  In addition, there were differences in the ways ZPICs were 
reporting on ZPIC-initiated work, and one ZPIC found the definitions 
regarding overpayments unclear.   
The inaccuracy and nonuniformity of ZPICs data prevented a 
conclusive assessment of ZPICs program integrity activities.  One 
of our objectives was to describe the extent of ZPICs program integrity 
activities during their first year of operation.  However, the inaccuracies 
and lack of uniformity in the ZPICs data prevented us from making a 
conclusive assessment of their activities.   
The lack of uniformity in ZPICs reporting of data is similar to issues we 
identified more than 10 years ago in a review of Medicare Part A fraud 
units.  That review found that definitions of key terms varied in 
meaning among CMS and its contractors, which hindered CMSs ability 
to interpret data and measure fraud unit performance.  In addition, 
despite CMSs statement that its new contracting strategy of realigning 
contractor jurisdictions to include both Medicare Parts A and B would 
make it easier for CMS to compare contractors, the lack of uniformity 
identified in ZPICs reporting could prevent CMS from both accurately 
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  ii    
   
E X E C U T I V E   S U M M A R Y  
measuring an individual ZPICs performance and comparing workload 
statistics across ZPICs.   
CMSs performance evaluations of ZPICs contained few workload 
statistics.  Neither ZPIC evaluation contained the amount of 
overpayments referred or the number of investigations or cases initiated 
as a result of proactive methods.  The performance evaluations provided 
limited information on requests for information.  Also, while one ZPICs 
evaluation included the number of investigations the ZPIC initiated, the 
other did not.  This lack of quantitative workload data is similar to the 
results of our past work on PSC performance evaluations, which found 
that the evaluation reports provided limited quantitative data about 
PSCs achievements.   
Although the ZPIC Statement of Work does not specify that workload 
statistics should be included in CMSs performance evaluations of the 
ZPICs, it does state that CMS uses CMS ARTS data to track and 
analyze ZPIC workload, performance, and production.  Therefore, 
including workload statistics in ZPICs performance evaluations would 
help ensure that CMS performs a thorough assessment of ZPICs 
performance. 
Data access issues affected ZPICs ability to perform program 
integrity activities.  ZPICs reported that data access issues affected their 
ability to identify potential fraud and abuse, respond to requests for 
information, and track overpayment collections.  At the start of their 
contracts, ZPICs had difficulties obtaining data.  One ZPIC described 
difficulties obtaining claims data from a previous PSC and, therefore, 
decided to purchase the claims data on its own from another CMS 
contractor.  The other ZPIC stated that the data necessary to fulfill 
requests for information were not available or had to be generated from 
multiple sources.   
Both ZPICs reported that improved data access would assist them in 
identifying potential fraud and abuse.  ZPICs reported that having access 
to daily downloads of claims data would enable them to perform  
near-real-time analysis of a providers or a suppliers billing activity.  
Both ZPICs identified issues with tracking overpayment collections 
relating to home health and durable medical equipment.  They explained 
that the format of overpayment reports received from Medicare 
administrative contractors (MAC) makes it difficult to identify the 
overpayments related to their jurisdictions.   
   
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E X E C U T I V E   S U M M A R Y  
RECOMMENDATIONS  
OIG has a long history of reviewing Medicares program integrity 
contractors and their ability to detect and deter fraud, waste, and abuse.  
This review covered the first two ZPICs first year of operation.  
Conducting an initial assessment of the two ZPICs activities provides 
CMS with important information that would be helpful in its oversight 
of all ZPICs performance.  The inaccuracies and lack of uniformity we 
identified in ZPICs data prevented us from making a conclusive 
assessment of their program integrity activities; however, the issues we 
identified present a serious obstacle to CMS in effectively overseeing 
ZPIC operations.  It is important that these issues be corrected so that 
CMS can analyze ZPICs effectiveness in detecting and deterring fraud, 
waste, and abuse.  It is also important that these issues be corrected so 
that CMS can determine how well ZPICs are performing compared to 
other ZPICs and PSCs.  Therefore, we recommend that CMS:  
Clarify the workload definitions in CMS ARTS to ensure that ZPICs 
workload statistics are accurate and that ZPICs report their data 
uniformly.  CMS should clarify the definitions of the workload statistic 
fields in CMS ARTS and discuss the definitions with the ZPICs to ensure 
uniformity of reporting across ZPICs.      
Improve oversight of ZPICs by performing a timely review of data in 
CMS ARTS for each ZPIC and across ZPICs to detect any anomalies 
in workload reporting.  This would enable CMS to identify any issues 
that need to be further addressed and identify ZPICs that may need 
further oversight.   
Utilize and report ZPIC workload statistics in ZPIC evaluations.  CMS 
requires ZPICs to report workload statistics in CMS ARTS that could be 
valuable to CMS in its oversight and evaluation of ZPICs.  Once CMS has 
ensured that ZPICs workload statistics are being accurately and 
uniformly reported, CMS should utilize and report these statistics in 
ZPICs performance evaluations.   
Ensure that ZPICs have access to all data necessary to effectively 
carry out their program integrity activities.  CMS should ensure that 
ZPICs have all data necessary to improve their identification of potential 
fraud and abuse, respond to requests for information, and track 
overpayment collections.  For example, CMS should ensure that ZPICs 
have access to the necessary claims data at the start of their contracts, 
have access to near-real-time data, and receive MAC overpayment 
reports that are separated by ZPIC jurisdiction.      
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E X E C U T I V E   S U M M A R Y  
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE  
CMS believes it has already complied with our first recommendation.  
CMS stated that there were some early misunderstandings, which have 
since been clarified, and believes the workload definitions are now 
written clearly.   
CMS concurred with the first part of our second recommendation, to 
perform a timely review of data in CMS ARTS for each ZPIC.  It did not 
concur with the second part, to perform a timely review of data across 
ZPICs.  CMS stated that anomalies cannot be detected across ZPICs 
because of the differences in fraud landscapes between the ZPICs.  We 
disagree and note that we detected anomalies in reporting across ZPICs, 
including differences in the way the ZPICs were reporting their 
numbers of new investigations.   
CMS partially concurred with our third recommendation and stated it 
will consider including workload statistics for future evaluations, if 
appropriate.  CMS stated it would welcome the opportunity to meet 
with OIG to discuss any workload statistics OIG believes would relate 
directly to ZPICs performance.   
CMS concurred with our fourth recommendation and stated that the 
currently awarded ZPIC Statements of Work require ZPICs to have 
access to daily downloads of shared system claims data.  Additionally, 
CMS stated that it believes an effective workaround was developed for 
every data access problem identified in our study.   
 
 
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 T A B L E   O F   C O N T E N T S  
EX ECUT I VE  SUM M ARY  .....................................i 
 
 
I NT RO DU CT I O N  ............................................ 1 
 
 
F I NDI NG S  .................................................  11 
  Workload data used by CMS to oversee ZPICs were not accurate         
or uniform .............................................  11 
  The inaccuracy and nonuniformity of ZPICs data prevented a 
conclusive assessment of ZPICs program integrity activities ....  14 
  CMSs performance evaluations of ZPICs contained few  
workload statistics ......................................  15 
  Data access issues affected ZPICs ability to perform program 
integrity activities ......................................  16 
 
 
RECO M M END AT I O N S  ..................................... 18 
  Agency Comments and Office of Inspector General Response .... 19 
 
 
APP EN DI X ES  ............................................. 21 
  A:  Definitions for Selected Workload Data Fields in the Centers  
 for Medicare & Medicaid Services Analysis, Reporting, and 
 Tracking System ..................................... 21 
B:  Zone Program Integrity Contractors Program Integrity  
 Activities and Workload Data .......................... 24  
C:  Agency Comments ...................................  32 
 
 
ACKNO WL E DG M E N T S .....................................  36 
 
    
   
 I N T R O D U C T I O N  
OBJECTIVES  
1.  To perform an early assessment of the Centers for Medicare & 
Medicaid Services (CMS) oversight of the Zone Program Integrity 
Contractors (ZPIC).    
2.  To describe the extent to which ZPICs performed program 
integrity activities, including investigations, case referrals, 
responses to requests for information, and administrative actions. 
3.  To determine the extent to which CMS used program integrity 
workload statistics in ZPIC performance evaluations.  
4.  To describe any barriers encountered by ZPICs in performing their 
Medicare program integrity activities.  
BACKGROUND 
This study is part of the Office of Inspector Generals (OIG) body of work 
examining the identification and investigation of fraud, waste, and 
abuse by Medicare program integrity contractors.  OIG has identified 
oversight of CMS program and benefit integrity contractors as a top 
management challenge for the Department of Health and Human 
Services.  Previous OIG studies found vulnerabilities in these 
contractors efforts to combat fraud and abuse.  This is the first study 
examining ZPICs program integrity activities; it focuses on the two 
ZPICs that completed a full contract year in 2009.   
Recently, there has been congressional interest in the work of the 
ZPICs.  The Senate Committee on Finance sent a letter to CMS on 
October 15, 2010, regarding the performance both of the Program 
Safeguard Contactors (PSC) and ZPICs.1  The letter raised concerns 
about the effectiveness of PSC and ZPIC efforts to combat fraud and 
abuse in the Medicare program.  
Transition From PSCs to ZPICs 
The Medicare Prescription Drug, Improvement and Modernization Act 
of 2003 required CMS to implement Medicare contracting reform.  As a 
result of contracting reform, CMS is replacing PSCs with ZPICs, which 
will perform program integrity work for Medicare Parts A and B in 
seven newly established geographical zones: 
 
1 Accessed at http://grassley.senate.gov/about/upload/2010-10-15-Letter-to-CMS.pdf  
on October 21, 2010.   
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I N T R O D U C T I O N  
  Zone 1:  American Samoa, California, Guam, Hawaii, the 
Mariana Islands, and Nevada.  
  Zone 2:  Alaska, Arizona, Idaho, Iowa, Kansas, Missouri, 
Montana, Nebraska, North Dakota, Oregon, South Dakota, 
Utah, Washington, and Wyoming.  
  Zone 3:  Illinois, Indiana, Kentucky, Michigan, Minnesota, 
Ohio, and Wisconsin.  
  Zone 4:  Colorado, New Mexico, Oklahoma, and Texas.  
  Zone 5:  Alabama, Arkansas, Georgia, Louisiana, 
Mississippi, North Carolina, South Carolina, Tennessee, 
Virginia, and West Virginia. 
  Zone 6:  Connecticut, Delaware, Maine, Maryland, 
Massachusetts, New Hampshire, New Jersey, New York, 
Pennsylvania, Rhode Island, Vermont, and  
Washington, D.C. 
  Zone 7:  Florida, Puerto Rico, and the Virgin Islands.  
CMS awarded the first two ZPIC contracts, for Zones 4 and 7, on 
September 30, 2008, and both ZPICs were fully operational as of  
February 1, 2009.  Health Integrity, LLC, was awarded the Zone 4 
contract and SafeGuard Services, LLC, was awarded the Zone 7 
contract.   
As of September 2011, CMS had awarded the remaining five ZPIC 
contracts.  Zone 1 was awarded in September 2010 and was fully 
operational in December 2010.  Zone 2 was awarded in September 2009, 
but the award was protested.  The protest was resolved in October 2010, 
and Zone 2 was fully operational in February 2011.  Zone 3 was 
awarded in April 2011; however, a postaward protest has delayed the 
transition.  Zone 5 was awarded in February 2009, but the award was 
protested and a stay of performance was required.  CMS provided 
justification to override the stay, and the ZPIC was fully operational in 
December 2009.  The last ZPIC contract for Zone 6 was awarded on 
September 30, 2011.      
Program Integrity Activities of the ZPICs 
According to the ZPIC Statement of Work, ZPICs activities to identify, 
prevent, or correct potential fraud, waste, and abuse may include, but 
are not limited to, the following:  
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  2    
   
I N T R O D U C T I O N  
  proactively pursuing different sources and techniques for 
analyzing data, 
  performing investigations, 
  referring cases to law enforcement,  
  initiating appropriate administrative actions, and  
  responding to requests for information from law 
enforcement.  
The ZPIC Statement of Work establishes the fundamental activities 
that may be performed by ZPICs and awarded through individual task 
orders.  CMS has awarded several task orders to ZPICs.  Each task 
order specifies the requirements to be performed.  One type of task 
order is the fee-for-service task order; hereinafter, we refer to this as the 
benefit integrity task order.2   This task order involves performing 
program integrity work for Medicare Part A, Part B, durable medical 
equipment (DME), and home health and hospice (HH&H).3     
As shown in Table 1 below, the Zone 4 ZPIC received $11.4 million and 
the Zone 7 ZPIC received $10.8 million to conduct activities under their 
benefit integrity task orders for the first contract year  
(September 30, 2008, through October 31, 2009).  In 2009, Zone 4s 
jurisdiction included 9 million beneficiaries and 107 million paid claims 
totaling $33 billion.  Zone 7s jurisdiction included 7 million 
beneficiaries and 96 million paid claims totaling $26 billion.   
 
Table 1:  ZPIC Funding for First Contract Year and Oversight 
Responsibility for Benefit Integrity Task Order for 2009 
ZPIC Funding  Number of  Number of   Dollar Amount 
9/30/0810/31/09  Beneficiaries   Paid Claims   of Paid Claims 
 
Zone 4  $11.4 million  9 million  107 million  $33 billion 
Zone 7  $10.8 million  7 million  96 million  $26 billion 
Source:  ZPIC task orders and OIG analysis of data received from CMS, December 2010.   
   
 
2 Other types of task orders that CMS has awarded include, for example, one that 
addresses the Medicare-Medicaid data match program and one that addresses home health 
fraud specifically in the Miami-Dade, Florida, area.  
3 Although DME services are included in Part B and HH&H services are included in  
Part A, the benefit integrity task order separates these types of services in its reporting.  
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CMS Oversight of ZPICs Program Integrity Activities 
Workload activity statistics.  ZPICs are required to report monthly 
workload statistics related to their benefit integrity task orders to CMS.  
These statistics are reported in an online system called the CMS 
Analysis, Reporting, and Tracking System (CMS ARTS).  According to 
the ZPIC Statement of Work, CMS uses CMS ARTS to track and 
analyze ZPICs workload statistics and performance.   
Within CMS ARTS, the workload statistics are tracked in specific 
templates, which are described below.   
Benefit Integrity template.  Statistics in this template include, but are not 
limited to: 
  number of new investigations and new cases resulting 
from proactive methods (e.g., data analysis), 
  number of new investigations and new cases originating 
from external sources (e.g., complaints), 
  amount of overpayments referred to and recovered by the 
affiliated contractor/Medicare administrative contractor 
(AC/MAC),4 and  
  administrative actions initiated (e.g., number of payment 
suspensions, exclusions, civil monetary penalties, and 
autodeny edits). 
Workload statistics in this template are reported separately for Part A, 
Part B, DME, and HH&H.   
Requests for Information template.  Statistics in this template include, but 
are not limited to: 
  number of information/data analysis requests received 
from OIG and the Department of Justice (DOJ) for  
ZPIC-initiated and non-ZPIC-initiated cases; 
  number of information/data analysis requests completed 
for OIG and DOJ; and 
  number of information/data analysis requests received 
from, and completed for, entities other than OIG and DOJ. 
 
4 AC/MACs are the contractors that process Medicare Parts A and B claims and recoup 
overpayments referred by ZPICs.  
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I N T R O D U C T I O N  
CMS provides definitions for ZPICs to use when reporting workload 
data.  Appendix A contains definitions for selected workload statistics.  
In addition, ZPICs include narrative information in the Benefit 
Integrity and Requests for Information templates to provide details on 
any significant workload activity.   
Quality Assurance and Improvement template.  One section of this 
template requests monthly ZPIC workload statistics regarding 
timeliness of responses to requests for information.  ZPICs are required 
to report these statistics separately for requests from OIG and DOJ.  
The statistics are also tracked separately for Priority I and Priority II 
requests.  Priority I requests are top priority and are required to be 
fulfilled within 30 days.  Priority II requests are less critical and are 
required to be fulfilled within 45 days.  Specifically, ZPICs report the 
number of Priority I and Priority II requests completed year-to-date and 
the number of these that were fulfilled within the required timeframes.   
Quarterly Requests for Information reports.  At the time of our review, 
ZPICs were required to submit quarterly reports on law enforcement 
requests.  These reports provide more detailed information than the 
monthly statistics.  The quarterly reports contain information such as 
the source of the request, whether it was Priority I or Priority II, 
whether it was open or closed, the date it was received, the date it was 
closed, and a description.  As of October 2010, ZPICs were no longer 
required to submit these quarterly reports, but instead are required to 
enter their requests for information into the Fraud Investigation 
Database.5   
ZPIC Performance Evaluations 
According to the ZPIC Statement of Work, ZPICs performance for each 
task order will be evaluated annually by CMS, with the first evaluation 
review occurring approximately 6 months after the task order is 
awarded.  The Performance Evaluation Team (PET) may evaluate any 
requirement in the Statement of Work that is related to the task order 
awarded.  The objectives of the performance evaluation include: 
  measuring and evaluating ZPICs performance, 
  identifying opportunities to improve performance,  
 
5 The Fraud Investigation Database is a CMS system that contains data on Medicare and 
Medicaid investigations, cases, requests for information, and payment suspensions.  
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  5    
   
I N T R O D U C T I O N  
  providing a fair and accurate system of review for CMS to 
ensure effective and efficient Medicare and Medicaid 
program administration, and 
  assessing the degree to which ZPICs direct and indirect 
customers are satisfied with ZPIC services. 
Some examples of potential data sources described in the ZPIC 
Statement of Work that may be used to evaluate performance include: 
  ZPIC-supplied dataEach ZPIC is required to prepare a 
self-evaluation of its performance.  This will be considered 
as part of the annual performance evaluation. 
  Internal controlsCMS may conduct internal control 
reviews of ZPICs and include the results in their 
performance evaluations. 
  PET investigationsPET may investigate any aspect of 
ZPIC activities and include findings as part of the 
performance evaluations. 
Related Studies by OIG  
Previous OIG studies have found vulnerabilities in Medicare program 
integrity contractors efforts to identify and investigate potential fraud 
and abuse as well as limitations in CMSs oversight of these contractors.  
In November 1998, OIG issued a report entitled Fiscal Intermediary 
Fraud Units (OEI-03-97-00350).  OIG found that key words, including 
complaint and case, varied in meaning among CMS and its 
contractors, which hindered CMSs ability to interpret fraud unit data 
and measure fraud unit performance.  OIG recommended that CMS 
establish clear definitions of key words, establish a standard set of data 
that can be used to measure fraud units performance, and include this 
standard set of data in all contractor performance evaluation reports. 
In March 2006, OIG issued a report entitled Medicares Program 
Safeguard Contractors:  Performance Evaluation Reports  
(OEI-03-04-00050).  OIG found that PSC performance evaluation 
reports provided limited quantitative data about PSCs achievements 
related to detecting and deterring fraud and abuse.   
In July 2007, OIG issued a report entitled Medicares Program 
Safeguard Contractors:  Activities To Detect and Deter Fraud and 
Abuse (OEI-03-06-00010).  OIG found that PSCs differed substantially 
in their number of new investigations and case referrals and 
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recommended that CMS review PSCs with low activity.  In response to 
this report, CMS stated that its new PSC (and now ZPIC) contracting 
strategy, which realigns contractor jurisdictions to include both 
Medicare Parts A and B, would make it easier to compare contractors.  
CMS also stated that improvements within CMS ARTS would prevent 
inconsistent reporting across contractors.  
In May 2010, OIG issued a report entitled Collection Status of Medicare 
Overpayments Identified by Program Safeguard Contractors 
(OEI-03-08-00030).  OIG found that overpayments that PSCs referred 
for collection did not result in significant recoveries to Medicare.  
Specifically, claims processors collected 7 percent, or $55 million, of the 
$835 million in overpayments that PSCs referred in 2007.  In response 
to this report, CMS stated that it was adding reporting requirements 
that would improve overpayment tracking among the MACs and 
PSCs/ZPICs.   
METHODOLOGY 
Scope  
Our study was limited to ZPICs in Zones 4 and 7 because they were the 
only ZPICs that had completed a full contract year at the time of our 
review.  We focused on investigation and fraud case workloads as well 
as requests for information and administrative actions related to ZPICs 
benefit integrity task orders during their first year of operation 
(February 1 through October 31, 2009).6  In addition, we gathered 
information from the ZPICs regarding any barriers they encountered 
while performing their contractual duties during their first full contract 
year (September 30, 2008, through October 31, 2009). 
Data Collection  
We collected data from CMS and ZPICs in Zones 4 and 7.  We collected 
data from February through December 2010 and performed followup 
from January through March 2011.     
Data from CMS.  From CMS, we collected ZPICs workload statistics 
from the CMS ARTS Benefit Integrity, Requests for Information, and 
 
6 The first contract year for the ZPICs in Zones 4 and 7 was September 30, 2008, through 
October 31, 2009.  However, because the ZPICs were in transition and were not fully 
operational until February 1, 2009, we reviewed only workload statistics for the period 
when they were fully operational.  We refer to this period as their first year of operation for 
simplicity.  
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Quality Assurance and Improvement templates.  We collected workload 
data for each month during the ZPICs first year of operation, beginning 
with February 2009 and ending with October 2009.  We also collected 
summary workload data for the 9-month timeframe.  In addition, we 
collected the narratives included in the Benefit Integrity and Requests 
for Information templates.  We also collected the quarterly law 
enforcement Requests for Information reports for the ZPICs first year of 
operation.   
Additionally, we reviewed the CMS ARTS workload definitions and 
contacted CMS staff to obtain clarification on the definitions and to help 
resolve discrepancies in the workload data.   
We also requested performance evaluations for the ZPICs first contract 
year.  For each ZPIC, we received a performance evaluation report that 
covered the period September 30, 2008, through April 30, 2009.  As of 
March 2011, evaluation reports covering the period May 1 through 
October 31, 2009, had not been completed.   
Data from ZPICs.  We sent each ZPIC its Benefit Integrity and Requests 
for Information workload data, which we had received from CMS.  We 
asked ZPICs to review the information to ensure its accuracy and either 
confirm that it was correct or provide corrected information.  We did not 
ask ZPICs to review their data in the Quality Assurance and 
Improvement template.   
To obtain additional information, we sent a data collection instrument 
to the ZPICs.  The information collected included the types of potential 
fraud and abuse investigated and referred to OIG, the types of proactive 
data analysis conducted, and the number of overpayment recoupment 
actions related to cases.  We also requested information about any 
barriers encountered relating to data access, fraud and abuse 
investigation, referrals for administrative actions, and responding to 
requests for information.   
Data Analysis  
We reviewed the workload data in the Benefit Integrity template to 
identify any inconsistencies.  We analyzed data on ZPICs 
investigations, case referrals, and administrative actions by type of 
service.  We calculated the total number of investigations and cases 
handled by the ZPICs and aggregated the dollars associated with 
administrative actions (e.g., overpayments).  We also calculated the 
percentage of investigations and cases that originated from external 
sources and proactive methods.  We determined the percentage of 
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investigations, cases, and referred overpayment dollars associated with 
each type of service (i.e., Part A, Part B, DME, and HH&H).   
From the Requests for Information workload data, we determined the 
number of requests that ZPICs received from OIG, DOJ, and other 
entities during their first year of operation.  We compared the Requests 
for Information workload data to the data provided in the Requests for 
Information quarterly reports.   
We reviewed the requests for information data from the Quality 
Assurance and Improvement template to determine whether they 
corresponded to the data in the quarterly Requests for Information 
reports and to identify any inconsistencies in the template itself.     
We also used the quarterly Requests for Information reports and 
information in the Requests for Information workload narratives to 
determine the timeliness of ZPICs response to OIG and DOJ requests 
for information.  Appendix B provides a detailed explanation of our 
methodology for determining timeliness of requests for information.     
We reviewed the ZPICs performance evaluation reports to determine 
the extent to which they incorporated program integrity workload 
statistics.  In addition, we compared the data on the timeliness of 
requests for information in the performance evaluations with the 
timeliness data in the quarterly Requests for Information reports and 
the Quality Assurance and Improvement template. 
From the ZPIC survey, we aggregated the types of potential fraud and 
abuse that were investigated and referred to law enforcement, as well 
as the number of overpayment recoupment actions associated with 
cases.  We also identified the types of proactive data analysis conducted.  
Additionally, we compiled any barriers reported by the ZPICs regarding 
data access, performance of administrative actions, and response to 
requests for information.   
For ease of reporting, we differentiate between the ZPICs, when 
necessary, by referring to them as either ZPIC A or ZPIC B in our 
report.   
Limitations 
The program integrity workload data and survey information included 
in the report are self-reported by the ZPICs.  Although we asked ZPICs 
to verify the accuracy of their workload data, we did not independently 
validate the information.   
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I N T R O D U C T I O N  
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.    
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  10    
   
 F I N D I N G S  
There were inaccuracies and a 
Workload data used by CMS to oversee ZPICs 
lack of uniformity in ZPICs data 
were not accurate or uniform  
during their first year of 
operation (February through October 2009).  The inaccuracies and lack 
of uniformity resulted from system issues in CMS ARTS, ZPIC 
reporting errors, ZPICs interpretations of workload definitions, and 
inconsistencies in requests for information reports.   
System issues in CMS ARTS led to inaccurate ZPIC data  
In reviewing the original CMS ARTS data we received from CMS, we 
identified a system issue that led to inaccurate ZPIC workload data.  
Specifically, we identified two fields in the Benefit Integrity template 
that were not being calculated correctly in CMS ARTS.  The fields were 
Number of new investigations originating from reactive sources and 
Number of new cases referred originating from reactive sources.  The 
correct values for these fields should have been calculated by summing 
several data fields; however, CMS ARTS was not summing the fields 
correctly, resulting in incorrect totals.  A visual review of the workload 
data revealed the system error.  CMS worked with its CMS ARTS 
contractor to correct the system errors and, at our request, resubmitted 
the corrected data reports to us.  Appendix A contains the definitions of 
selected CMS ARTS workload statistics.     
ZPIC reporting errors led to inaccurate data in CMS ARTS 
Based on our initial review of ZPICs workload data, we found 
discrepancies that prompted us to request the ZPICs to review their 
data.  For example, we identified discrepancies between one ZPICs 
Request for Information workload data and the requests for information 
data in its quarterly reports.  Additionally, we identified discrepancies 
between the fields in CMS ARTS that capture the number of fraud cases 
open at the beginning of the month and the number open at the end of 
the month.  It did not appear that CMS had identified these 
discrepancies or had asked the ZPICs to review or revise their data. 
ZPICs reviewed their data and reported that some of the workload data 
they originally submitted to CMS were incorrect.  ZPIC A provided us 
with revised workload data that increased its number of requests for 
information received from 480 to 516.  ZPIC B provided us with revised 
workload data that increased the amount of its overpayment dollars 
recovered in 1 month from $0 to $155,174; ZPIC B also increased its 
total number of case referrals from seven to nine.   
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FF II NN DD II NN GG SS   
Moreover, according to the workload definitions, the number of cases 
that were open and active at the beginning of the month should equal 
the number of cases open and active at the end of the previous month. 
However, even after ZPICs submitted their revised data to us, we 
identified instances in which these numbers did not match.   
ZPICs interpretation of workload definitions led to a lack of uniformity in 
workload data  
New investigations.  Based on ZPICs workload data, ZPIC A opened  
404 new investigations and ZPIC B opened 2,409 new investigations.  
As shown in Table 2, ZPIC Bs number of investigations originating 
from external sources (e.g., complaints) was seven times higher than 
ZPIC As (2,305 versus 312).   
 
Table 2:  New ZPIC Investigations by Source  
External Source  Proactive Method  Total 
 
ZPIC A  312  92  404 
ZPIC B  2,305  104  2,409 
     Both ZPICs   2,617  196  2,813 
Source:  OIG analysis of ZPICs Benefit Integrity Workload data, February 1 through October 31, 2009. 
 
In reviewing ZPIC workload data and following up with ZPIC staff, we 
determined that the two ZPICs counted and reported their new 
investigations differently in their CMS ARTS workload statistics.  
Specifically, ZPIC B explained that it included all fraud complaints in 
its number of new investigations in CMS ARTS, regardless of whether 
those complaints were merged into one investigation of a particular 
provider.  However, ZPIC A explained that if it received one complaint 
on a particular provider and started an investigation and then received 
another complaint on the same provider, this would not be counted as a 
new investigation in the workload statistics.  This lack of uniformity in 
ZPICs reporting could account for the disparity between the ZPICs 
numbers of new investigations opened during our timeframe and could 
also affect CMSs ability to accurately assess ZPICs performance.     
ZPIC-initiated work.  In the workload statistics, ZPICs report whether 
requests for information submitted by OIG and DOJ were based on  
ZPIC-initiated cases or non-ZPIC-initiated cases.  The workload 
statistics showed that one ZPIC had no requests as a result of  
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  12    
   
FF II NN DD II NN GG SS   
ZPIC-initiated cases, whereas the other ZPIC reported that nearly all of 
its OIG/DOJ requests were results of ZPIC-initiated cases.  Because of 
this disparity, we followed up with the latter ZPIC and learned that it 
included its prior work as a PSC when reporting the number of requests 
it received as a result of ZPIC-initiated cases.  The ZPICs different 
interpretations of definitions involving ZPIC-initiated work could lead 
them to provide CMS with inaccurate data for reviewing performance in 
this area.       
Overpayments.  Several fields in the workload statistics capture 
information on overpayments; however, the definitions of these fields 
were problematic for at least one ZPIC.  As shown in Appendix A, three 
overpayment fields are located in the investigation workload section 
(fields A9, A10, and A14) and two overpayment fields are located in the 
fraud case workload section (fields B7 and B13).     
In reviewing one ZPICs survey and workload data, we identified an 
inconsistency and followed up with that ZPIC.  We learned that 
although the fields for Dollar amount referred to the AC/MAC for 
overpayment collection and Number of overpayment recoupment 
actions referred to the AC/MAC are located under the investigation 
workload section, the definitions do not indicate whether CMS is 
referring to overpayment referrals based on a case or an investigation.  
Therefore, this ZPIC included data relating to investigations and cases 
in both of these fields instead of just information related to 
investigations.7  This could prevent CMS from accurately identifying 
overpayments associated with investigations versus those associated 
with cases.   
Reports regarding requests for information were inconsistent 
The ZPICs quarterly Requests for Information reports and their 
Quality Assurance and Improvement reports each contain information 
regarding the number of OIG and DOJ requests for information 
completed and the ZPICs timeliness in completing these requests.  
However, we found inconsistencies regarding the ZPICs reporting of 
requests for information between the two reports.  For example, our 
analysis of one ZPICs quarterly report data from February through 
 
7 There is a field relating to the number of overpayment recoupment actions referred to 
the AC/MAC in the investigations workload area but not in the case workload area.  CMS 
staff reported that they were planning to add this field when they make system 
enhancements to CMS ARTS. 
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  13    
   
F I N D I N G S  
October 2009 showed that the ZPIC completed 31 Priority I requests for 
OIG, with 19 percent not completed within 30 days.  However, this 
ZPICs Quality Assurance and Improvement data for the same period 
indicated that the ZPIC completed just eight Priority I requests for OIG, 
with 25 percent not completed within 30 days.     
In addition, we found inconsistencies within the Quality Assurance and 
Improvement report from month to month.  For example, although 
ZPICs are instructed to report the number of requests completed  
year-to-date, we found instances in which the number of completed 
requests decreased from one month to the next.  Moreover, although 
ZPICs are instructed to report the number of Priority I requests for 
information completed year-to-date and the number of these requests 
fulfilled within 30 days, we observed instances in which the number of 
requests completed within the 30-day required timeframe was greater 
than the total number of requests completed.   
One of our objectives was to 
The inaccuracy and nonuniformity of ZPICs 
describe the extent of ZPICs 
data prevented a conclusive assessment of 
program integrity activities 
ZPICs program integrity activities 
during their first year of operation 
(February through October 2009).  However, the inaccuracies and lack 
of uniformity in the ZPICs data prevented us from making a conclusive 
assessment of their activities.   
We have provided ZPICs workload data and data obtained through our 
survey in Appendix B to give a general sense of the ZPICs self-reported 
program integrity activities.  Appendix B provides information on 
ZPICs investigation and case referral activity, utilization of external 
and proactive methods, activities related to requests for information, 
and activities related to overpayments and other administrative actions.  
The inconsistencies we identified in ZPICs reporting are similar to the 
issues we identified more than 10 years ago in our review of Medicare 
fraud units.8  In that report, we found that definitions of key terms, 
including complaint and case, varied in meaning among CMS and its 
contractors, which hindered CMSs ability to interpret data and 
measure fraud unit performance.  Similarly, the inconsistencies and 
lack of uniformity we identified in ZPICs reporting could prevent CMS 
from performing effective oversight of the ZPICs.  
 
8 OIG, Fiscal Intermediary Fraud Units, OEI-03-97-00350, November 1998.   
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FFFF IIII NNNN DDDD IIII NNNN GGGG SSSS     
In response to our previous work on PSCs identification of potential 
fraud and abuse, CMS stated that its new contracting strategy of 
realigning contractor jurisdictions to include both Medicare Parts A  
and B would make it easier to compare contractors.9  CMS also stated 
that improvements within CMS ARTS would prevent inconsistent 
reporting across contractors.  However, our current review has 
identified incorrect and nonuniform reporting in CMS ARTS that could 
prevent CMS from both accurately measuring an individual ZPICs 
performance and comparing workload statistics across ZPICs. 
CMS did not include the results of 
CMSs performance evaluations of ZPICs 
many workload statistics in ZPICs 
contained few workload statistics   performance evaluation reports.  
Neither ZPIC evaluation included 
the number or percentage of investigations or cases initiated as a result 
of proactive methods.  Additionally, neither evaluation reported on the 
number of overpayment actions initiated or the overpayment dollars 
referred.  While one ZPICs evaluation included the number of 
investigations initiated, the other did not.  This lack of quantitative 
workload data is similar to the results of our past work on PSC 
performance evaluations, which found that PSC evaluation reports 
provided limited quantitative data about PSCs achievements related to 
detecting and deterring fraud and abuse. 10   
Both ZPICs evaluations did provide some information on the timeliness 
of requests for information.  However, one ZPICs evaluation report 
provided the average response time for completing Priority I and 
Priority II requests but did not provide information on the number of 
requests completed or the number that exceeded the required 
timeframes.  The other ZPICs evaluation report provided the number of 
Priority I requests that were completed and the number that exceeded 
the timeframe; however, these data did not coincide with the data 
provided in the ZPICs Requests for Information quarterly reports or in 
the Quality Assurance and Improvement template.   
Although the ZPIC Statement of Work does not specify that workload 
statistics should be included in CMSs performance evaluations of the 
 
9 OIG, Medicares Program Safeguard Contractors:  Activities To Detect and Deter Fraud 
and Abuse, OEI-03-06-00010, July 2007.   
10 OIG, Medicares Program Safeguard Contractors:  Performance Evaluation Reports 
(OEI-03-04-00050), March 2006.  
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  15    
   
F I N D I N G S  
ZPICs, it does state that CMS uses CMS ARTS data to track and 
analyze ZPIC workload, performance, and production.  Including 
workload statistics in ZPICs performance evaluations would help 
ensure that CMS performs a thorough assessment of ZPICs 
performance.  
Data access issues affected ZPICs ability to  ZPICs reported that data access 
issues affected their ability to 
perform program integrity activities 
identify potential fraud and abuse, 
respond to requests for information, and track overpayment collections.   
At the start of their contracts, ZPICs had difficulties obtaining data.  As 
outlined in the Statement of Work, ZPICs were required to obtain  
3 years worth of Medicare claims data.  According to CMS staff, the 
outgoing PSCs were to provide these data to the ZPICs.  However,  
ZPIC A described difficulties obtaining claims data from a previous PSC 
and, therefore, decided to purchase the claims data on its own from 
another CMS contractor.  This caused a 30-day delay in data 
availability during the first month of operations.  ZPIC B stated that at 
the beginning of its contract, the data necessary to fulfill the requests 
for information were not available or had to be generated from multiple 
sources.  For a short time, this ZPIC contracted with a prior PSC to 
fulfill DME requests for information because the data being requested 
were not available to the ZPIC.   
Both ZPICs reported that improved data access would assist them in 
identifying potential fraud and abuse.  The ZPICs explained that it 
would be beneficial to have access to daily downloads of Part A, Part B, 
DME, and HH&H claims data.  This would enable the ZPICs to perform 
near-real-time analysis of a providers or suppliers billing activity.  The 
ZPICs explained that they are working with CMS to receive access to 
these data.  Additionally, one ZPIC reported that having access to 
Medicare Part C and Part D data would enable the ZPIC to have a full 
picture of a providers billing pattern.   
In response to our previous work on the collection status of PSCs 
overpayments, CMS stated that it had issued new requirements for 
ZPICs and MACs to assist with overpayment reporting.11  However, 
ZPICs identified barriers to tracking overpayment collections relating to 
 
11 OIG, Collection Status of Medicare Overpayments Identified by Program Safeguard 
Contractors  (OEI-03-08-00030), May 2010.   
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F I N D I N G S  
home health and DME.  The ZPICs reported that the format of the 
overpayment reports received from Medicare claims processors makes it 
difficult to identify the overpayments related to their jurisdictions. 
ZPIC A stated that it has worked with the MACs and now can properly 
identify the majority of the money collected.  ZPIC B reported that its 
issues relating to home health had been resolved but that it was still 
having issues with the overpayments relating to DME.  The ZPIC 
explained that the overpayment recoupment report provided by the 
MAC does not enable the ZPIC to track the money collected on its 
overpayment referrals.   
 
 
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 R E C O M M E N D A T I O N S  
OIG has a long history of reviewing Medicares program integrity 
contractors and their ability to detect and deter fraud, waste, and abuse.  
This review covered the first two ZPICs first year of operation.  
Conducting an initial assessment of the two ZPICs activities provides 
CMS with important information that would be helpful in its oversight 
of all ZPICs performance.   
Although one of our objectives was to describe the extent of ZPICs 
program integrity activities, the inaccuracies and lack of uniformity we 
identified in ZPICs data prevented us from making a conclusive 
assessment of their activities.  Additionally, we found that data access 
issues affected ZPICs ability to perform program integrity activities.     
Moreover, some of the issues we identified are similar to past OIG 
report findings.  Specifically, the lack of uniformity in ZPICs reporting 
is similar to what we found regarding Medicare Part A fraud units more 
than a decade ago.  Furthermore, the lack of quantitative workload data 
in ZPICs performance evaluations is similar to the results we identified 
more than 5 years ago in our work on PSC performance evaluations.   
Additionally, although CMS has stated that its new contracting 
strategy, which realigns contractor jurisdictions to include both 
Medicare Parts A and B, would make it easier to compare contractors, 
the issues we identified could prevent CMS from accurately comparing 
workload data across ZPICs.   
The issues we identified have been problematic for some time and 
present a serious obstacle to CMS in effectively overseeing ZPIC 
operations.  These issues need to be corrected so that CMS can analyze 
ZPICs effectiveness in detecting and deterring fraud, waste, and abuse.  
Correcting these issues also will enable CMS to determine how well 
ZPICs are performing compared to other ZPICs and PSCs.  Therefore, 
we recommend that CMS:  
Clarify the workload definitions in CMS ARTS to ensure that ZPICs workload 
statistics are accurate and that ZPICs report their data uniformly 
CMS should clarify the definitions of the workload statistic fields in 
CMS ARTS and discuss the definitions with the ZPICs to ensure 
uniformity of reporting across ZPICs.   
   
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  18    
   
RRR EEE CCC OOO MMM MMM EEE NNN DDD AAA TTT III OOO NNN SSS    
Improve oversight of ZPICs by performing a timely review of the data in CMS 
ARTS for each ZPIC and across ZPICs to detect any anomalies in workload 
reporting   
This would enable CMS to identify any issues that need to be further 
addressed and identify ZPICs that may need further oversight.   
Utilize and report ZPIC workload statistics in ZPIC evaluations 
CMS requires ZPICs to report workload statistics in CMS ARTS that 
could be valuable to CMS in its oversight and evaluation of ZPICs.  
Once CMS has ensured that ZPICs workload statistics are being 
accurately and uniformly reported, CMS should utilize and report these 
statistics in ZPICs performance evaluations.   
Ensure that ZPICs have access to all data necessary to effectively carry out 
their program integrity activities 
CMS should ensure that ZPICs have all data necessary to improve their 
identification of potential fraud and abuse, respond to requests for 
information, and track overpayment collections.  For example, CMS 
should ensure that ZPICs have access to the necessary claims data at 
the start of their contracts, have access to near-real-time data, and 
receive MAC overpayment reports that are separated by ZPIC 
jurisdiction to enable ZPICs to determine which recovered 
overpayments are associated with their overpayment referrals.   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS believes it has already complied with our first recommendation.  
CMS stated that there were some early misunderstandings, which have 
since been clarified, and believes the workload definitions are now 
written clearly.  We ask that CMS, in its final management decision, 
provide OIG with documentation of the revised definitions.   
CMS concurred with the first part of our second recommendation, to 
perform a timely review of data in CMS ARTS for each ZPIC.  CMS 
stated that it has developed a monthly dashboard of key statistical 
indicators in CMS ARTS.  However, CMS did not state how often it was 
reviewing these indicators along with ZPICs other monthly workload 
statistics to detect any anomalies in ZPIC reporting.  CMS did not 
concur with the second part of our recommendation, to perform a timely 
review of data across ZPICs.  In response to our previous work on PSCs 
identification of potential fraud and abuse, CMS stated that its new 
strategy of realigning contractor jurisdictions to include both Medicare 
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  19    
   
R E C O M M E N D A T I O N S  
Parts A and B would make it easier to compare contractors.  However, 
in its current comments, CMS stated that this new strategy does not 
make it possible to compare the zones and that anomalies cannot be 
detected across ZPICs because of the differences in fraud landscapes 
between the ZPICs.  We disagree and note that we detected anomalies 
in reporting across ZPICs, including differences in the way the ZPICs 
were reporting their numbers of new investigations.  We maintain that 
reviewing data across ZPICs will enable CMS to detect anomalies in 
workload reporting and identify ZPICs that may need additional 
oversight.   
CMS partially concurred with our third recommendation and stated it 
will consider including workload statistics for future evaluations, if 
appropriate.  CMS stated that it cannot evaluate a ZPIC based on the 
number or percentage of investigations or cases initiated as a result of 
proactive methods, the number of overpayment actions initiated, or the 
associated overpayment dollars referred.  CMS stated that these data 
can vary widely from month to month and are not a good indicator of 
performance because they are not within the control of the ZPIC.  OIG 
maintains that quantitative measures, such as the number of 
investigations and cases initiated as a result of proactive methods, are 
within the control of the ZPIC.  While these measures should not be the 
sole indicator of ZPIC performance, they can provide valuable 
information on the level of ZPIC activity and the quality of ZPIC 
performance.  OIG continues to support the need for both quantitative 
and qualitative measures in ZPICs performance evaluations.  CMS 
stated its willingness to work with OIG to identify workload statistics 
that would relate directly to ZPICs performance.   
CMS concurred with our fourth recommendation and stated that the 
currently awarded ZPIC Statements of Work require ZPICs to have 
access to daily downloads of shared system claims data.  Additionally, 
CMS stated that it believes an effective workaround was developed for 
every data access problem identified in our study.  The full text of 
CMSs comments is provided in Appendix C.   
   
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 A P P E N D I X ~ A  
 
Table A-1:  Definitions for Selected Workload Data Fields in the Centers for Medicare 
& Medicaid Services Analysis, Reporting, and Tracking System 
Field  Definition 
A. Investigation Workload 
This number reflects all new investigations originating from 
specific complaints and/or information.  This is a count of 
A3.  Number of new investigations originating from reactive 
investigations, not individual target providers within an 
sources  
investigation.  The amount reported in this field should total the 
workload entered in A3aA3e. 
This reflects the number of new investigations referred to the 
Zone Program Integrity Contractor (ZPIC) Benefit Integrity Unit 
A3a. Medical Review  (BIU) from the Affiliated Contractor /Medicare Administrative 
Contractor (AC/MAC) Medical Review unit (since the beginning 
of the month). 
This reflects the number of new investigations referred to the 
A3b.AC/MAC Complaint Unit   ZPIC BIU from the AC/MACs Complaint Unit (since the 
beginning of the month). 
This reflects the number of new investigations referred to the 
A3c. Other  ZPIC BIU from sources other than those specified above (since 
the beginning of the month). 
This reflects the number of new investigations originating from 
A3d. CMS Field Offices 
a CMS Field Office (since the beginning of the month). 
This reflects the number of new investigations referred to the 
A3e. Other ZPIC Task Orders  ZPIC BIU from other ZPIC Task Orders (since the beginning of 
the month). 
A4.  Number of new investigations resulting from proactive  This number reflects all new investigations originating from 
leads  self-initiated means.  
This reflects the number of investigations that are open and 
active in the ZPIC BIU at the end of the month.  The amount 
A7.  Number of investigations open and active at the end of the 
reported here reflects the amounts reported in 
month 
A1+A3+A4-A5-A6+any investigations reprioritized into an 
active status from A8. 
A9.  Dollar amount referred to the AC/MAC for overpayment  This reflects the dollar amount that the ZPIC BIU referred to 
collection  the AC/MAC for collection. 
This reflects the number of recoupment actions referred for 
A10.  Number of overpayment recoupment actions referred to 
overpayment that the ZPIC BIU submitted to the AC/MAC this 
the AC/MAC 
month. 
A14.  Dollar amount recovered on overpayments related to 
This reflects the actual dollar amount recovered as a result of 
investigations, determined by the ZPIC and referred to the 
ZPIC BIU recoupment actions referred to the AC/MAC. 
AC/MAC for collection 
B. Fraud Case Workload 
This reflects the number of fraud cases that are open and 
B1.  Number of fraud cases open and active at the beginning 
active at the beginning of the month.  This number should 
of the month 
equal B5 from the prior month.  
This number reflects all cases originating from the sources 
B2.  Number of new cases referred originating from reactive 
specified below and should total the workload entered in 
sources 
B2aB2e. 
This reflects the number of new cases referred by the ZPIC 
B2a. Medical Review  BIU that originated from the AC/MAC Medical Review unit 
(since the beginning of the month). 
This reflects the number of new cases referred by the ZPIC 
B2b. AC/MAC Complaint Unit   BIU that originated from the AC/MACs Complaint Unit (since 
the beginning of the month). 
 
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A P P E N D I X ~ A  
 
T able A-1:  Definitions for S elected Workload Data Fields in the Centers for Medicare 
& Medicaid Services' Analysis, Reporting, and Tracking System (Continued) 
Field   Definition 
This reflects the number of new cases referred by the ZPIC 
B2c. Other  BIU that originated from sources other than those specified 
above (since the beginning of the month). 
This reflects the number of new cases originating from CMS 
B2d.CMS Field Offices  
Field Offices during the month being reported on. 
This reflects the number of cases originating from other ZPIC 
B2e. Other ZPIC Task Orders 
Task Orders during the month being reported. 
B3.  Number of new cases referred resulting from proactive  This number reflects all new cases originating from  
leads   self- initiated means.  
This reflects the number of cases that are open and active in 
B5.  Number of cases open and active at the end of the month 
the ZPIC BIU at the end of the month. 
This reflects the dollar amount that the ZPIC BIU referred to 
B7.  Total dollars as a result of administrative action on cases 
the AC/MAC for collection on cases this month only. 
B13.  Dollar amount recovered on overpayments related to 
This reflects the actual dollar amount recovered as a result of 
cases, determined by the ZPIC and referred to the AC/MAC for 
ZPIC BIU recoupment actions referred to the AC/MAC. 
collection 
C.  Medical Review in Support of Benefit Integrity 
This reflects the total number of prepay claims denied, in part 
or in full.  Claims with a single line item denial shall be 
C1g.  Total number of prepay claims denied  considered a full prepay claim denial.  Claims that are denied 
based on lack of medical records following an Additional 
Documentation Request (ADR) shall also be included. 
This reflects the dollar amount of prepay claims denied 
represented in C1e.  Where line item or partial denials were 
C1g1.  The dollar amount of prepay claims denied  made, only include the actual amount denied as opposed to 
the total amount of the claim.  This shall include claim denials 
for lack of medical records following a nonresponse to an ADR. 
D.  Administrative Activities 
This reflects the number of official petitions submitted to CMS 
to suspend providers during the month.  Providers with multiple 
Provider Identification Numbers (PINs) assigned will be 
D1a.  Number of new payment suspension requests submitted 
considered as a single provider, even when multiple PINs are 
to CMS during the month 
suspended.  Providers assigned to Group Practices where the 
 
group is suspended as well, shall be considered as separate 
suspensions. 
 
D1b.  Number of payment suspension requests denied by  This reflects the number of official petitions submitted that were 
CMS during the month  denied by CMS during the month.   
   
This reflects the number of providers referred to the Office of 
D2a.  Number of providers newly referred for exclusion  the Inspector General (OIG) for exclusion during the month.  
 
D3a.  Number of Civil Monetary Penalties (CMP) referred to  This reflects the number of CMPs referred by the ZPIC to 
OIG or CMS for consideration  either CMS or OIG for consideration during the month.  
   
This reflects the number of new benefit integrity auto-deny 
D5a.  The number of new auto-deny edits recommended for  edits, created by the ZPIC either solely or jointly with the 
implementation  AC/MAC, that the ZPIC recommends for payment system 
implementation this month. 
This reflects the total number of ZPIC-recommended 
D5b.  The total number of ZPIC-recommended auto-deny edits 
auto-deny edits that were in place during any part of the 
that were in effect during the month 
month. 
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A P P E N D I X ~ A  
Table A-1:  Definitions for Selected Workload Data Fields in the Centers for Medicare 
 
& Medicaid Services' Analysis, Reporting, and Tracking System (Continued) 
 
Field  Definition 
E. Information/Data Requests 
E1a.  Number of information/data analysis requests received  This reflects the number of information/data analysis requests 
from the OIG/ Department of Justice (DOJ) for ZPIC initiated  (including requests for Medical Review) received from the 
cases  OIG/DOJ for ZPIC initiated cases this month. 
This reflects the number of information/data analysis requests 
E1b.  Number of information/data analysis requests received 
(including requests for Medical Review) received from the 
from the OIG/DOJ for non-ZPIC initiated cases 
OIG/DOJ for non-ZPIC initiated cases. 
This reflects the number of information/data analysis requests 
E1c.  Number of information/data analysis requests completed  completed for the OIG/DOJ during the month. This number 
for the OIG/DOJ  represents both ZPIC initiated and non-ZPIC initiated 
completions. 
This reflects the number of information/data analysis requests 
received from "Other." "Other" includes, but is not limited to, 
E2a.  Number of formal information/data analysis requests 
CMS, Internal Revenue Service (IRS), Medicaid Fraud Control 
received from "Other" Entities 
Units (MFCU), State Investigative Departments, or State 
Attorney General Offices. 
This reflects the number of information/data analysis requests 
completed for "Other" during the month. This number 
E2b.  Number of formal information/data analysis requests  represents both ZPIC initiated and non-ZPIC initiated 
completed for "Other" Entities  completions. "Other" includes, but is not limited to, CMS, IRS, 
MFCUs, State Investigative Departments, or State Attorney 
General Offices. 
 
Source:  CMS ARTS definitions document received from CMS, July 2010.   
 
 
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A P AP EP NP DE INXD  IB X  ~ B  
Zone Program Integrity Contractors Program Integrity Activities and Workload Data 
 
One of our objectives was to describe the extent of Zone Program Integrity Contractors (ZPIC) 
program integrity activities during their first year of operation (February through October 
2009).  In this appendix, we provide ZPICs workload data, as well as data obtained through 
our survey, to give a general sense of the program integrity activities as reported by the 
ZPICs.  However, inaccuracies and a lack of uniformity in the ZPICs data prevented us from 
making a conclusive assessment of their activities.   
 
ZPICs Investigation and Case Referral Activity 
 
ZPICs investigate potential fraud and abuse on the part of providers and suppliers that 
receive reimbursement under Medicare Parts A and B.  When ZPICs receive an allegation of 
fraud or identify a potentially fraudulent situation, they investigate to determine the facts 
and magnitude of the alleged fraud.  For example, ZPICs may review a sample of claims, 
interview a sample of beneficiaries, or perform data analysis to substantiate the allegation.  
ZPICs consult with the Office of Inspector General (OIG) on the facts of the investigation and 
obtain OIGs recommendation on whether the investigation should be further developed as a 
case referral.   
 
Table B-1 shows the number and percentage of new investigations opened by ZPICs by the 
types of services involved.  Table B-2 shows the number and percentage of cases referred to 
law enforcement by the types of services involved.  Table B-3 provides the types and 
percentages of potential fraud and abuse involved with ZPICs new investigations and case 
referrals.   
 
Table B-1:  New ZPIC Investigations by Type of Service 
Part A  Part B  DME2  HH&H2   
Number   Percentage  Number  Percentage  Number  Percentage  Number  Percentage  Total 
 
ZPIC A1  69  17%  165  41%  83  21%  87  22%  404 
ZPIC B1  1,295  54%  231  10%  818  34%  65  3%  2,409 
     Both  
1,364  48%  396  14%  901  32%  152  5%  2,813 
     ZPICs 
Source:  OIG analysis of ZPICs Benefit Integrity Workload data, February 1 through October 31, 2009.  
1 Percentages across the row do not total 100 percent because of rounding. 
2 DME refers to durable medical equipment and HH&H refers to home health and hospice.  
 
 
   
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A P P E N D I X ~ B  
Table B-2:  New ZPIC Case Referrals by Type of Service 
Part A  Part B  DME  HH&H   
Number  Percentage  Number  Percentage  Number  Percentage  Number  Percentage  Total 
 
ZPIC A  0  0%  28  67%  11  26%  3  7%  42 
ZPIC B1  2  22%  4  44%  3  33%  0  0%  9 
     Both  
2  4%  32  63%  14  27%  3  6%  51 
     ZPICs 
Source:  OIG analysis of ZPICs Benefit Integrity workload data, February 1 through October 31, 2009.  
1 Percentages across the row do not total 100 percent because of rounding. 
 
Table B-3:  Types and Percentages of Potential Fraud and Abuse Involved With 
ZPICs New Investigations and New Case Referrals 
Percentage of Total New  Percentage of Total New Case 
Types of Potential Fraud and Abuse  
Investigations  Referrals 
Billing for services not furnished or 
32%  26% 
supplies not provided  
Aberrant billing patternse.g., pattern of 
overutilization of services or outlier  18%  8% 
payments   
Vacant supplier location or shell provider   12%  18% 
Billing for medically unnecessary 
11%  19% 
services or supplies  
Utilizing compromised or stolen 
beneficiary health insurance claim 
10%  18% 
numbers or provider identification 
numbers 
Schemes of collusione.g., soliciting, 
offering, or receiving a kickback, bribe,  6%  1% 
or rebate   
Misrepresenting the beneficiary's 
condition or billing for services for 
4%  9% 
beneficiaries who do not meet Medicare 
coverage guidelines  
Misclassifications of Diagnosis-Related 
3%  0% 
Groups  
Altering medical documentation or claim 
1%  3% 
forms  
Other   4%   0% 
     Total  100%1  100%1 
Source:  OIG analysis of ZPICs survey response for first year of operation.   
1 Percentages do not total 100 percent because of rounding. 
   
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A P P E N D I X ~ B  
ZPICs Utilization of External and Proactive Methods 
 
ZPICs are required to pursue leads from both proactive methods and external sources to 
address potential fraud and abuse.  Proactive methods include, but are not limited to, data 
analysis and reviewing the Fraud Investigation Database, the Internet, and news media.  
Fraud leads from external sources include, but are not limited to, law enforcement referrals; 
Centers for Medicare & Medicaid Services (CMS) referrals; and beneficiary complaints, 
including those received from the affiliated contractor/Medicare administrative contractor 
(AC/MAC) complaint unit.  According to CMSs Medicare Program Integrity Manual (PIM), 
ZPICs ability to make use of available data and apply innovative analytical methodologies is 
critical to their success as benefit integrity contractors.    
 
Table B-4 shows the extent to which ZPICs used external sources and proactive methods to 
generate investigations during their first year of operation.  Table B-5 shows the extent to 
which ZPICs used external sources and proactive methods to generate cases during their first 
year of operation.  Table B-6 provides examples of proactive data analysis and other proactive 
methods used by ZPICs during their first year of operation. 
 
Table B-4:  New ZPIC Investigations by Source Used To Initiate the  
Investigation 
External Source  Proactive Method   
Number  Percentage  Number  Percentage  Total  
 
ZPIC A  312  77%  92  23%  404 
ZPIC B  2,305  96%  104  4%  2,409 
     Both ZPICs  2,617  93%  196  7%  2,813 
Source:  OIG analysis of ZPICs Benefit Integrity Workload data, February 1 through October 31, 2009.  
 
Table B-5:  New ZPIC Case Referrals by Source Used To Initiate the Case 
External Source  Proactive Method   
Number  Percentage  Number  Percentage  Total   
 
ZPIC A  19  45%  23  55%  42 
ZPIC B  4  44%  5  56%  9 
     Both ZPICs  23  45%  28  55%  51 
Source:  OIG analysis of ZPICs Benefit Integrity workload data, February 1 through October 31, 2009.  
 
   
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A P P E N D I X ~ B  
Table B-6:  Examples of Proactive Data Analysis and Other Proactive Methods Used 
by One or Both ZPICs  
Proactive Data Analysis 
  Review of billing patterns to identify spikes in providers billing patterns or to determine the top billing providers for 
particular specialties 
  Comparison of billings within a specialty or across the country related to particular procedure codes 
  Review of data to identify hospices in which a large percentage of Medicare patients were in hospice care for an 
unusually long period  
  Identification of beneficiaries who received an excessive number of episodes of home health benefits 
  Identification of Medicare beneficiaries who resided at an unusually long distance from the address of the DME 
supplier 
  Cross-referencing of the top 10 billers in Part A, Part B, DME, and home health 
  Verification that beneficiary had a diagnosis related to limb amputation for suppliers billing for prosthetic devices 
  Identification of Medicare providers who were on State lists of physicians with suspended licenses 
  Review of services for inpatient stays with the same admission and discharge dates 
  Identification of claims for ambulance services with no associated services 
Other Proactive Methods 
  Attendance at meetings with Program Safeguard Contractors, ZPICs, and MACs to discuss new trends and identify 
potentially fraudulent providers or suppliers 
  Review of news articles to identify any arrested individuals, followed by a determination of whether the identified 
individuals were Medicare providers 
  Visits with doctors who were beyond a certain age to verify that they were still practicing medicine  
Source:  OIG analysis of ZPICs survey responses, 2010.   
 
 
   
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A P P E N D I X ~ B  
ZPICs Activities Relating to Requests for Information 
 
ZPICs may be asked to provide beneficiary records or provider data to OIG, the Department of 
Justice (DOJ), or other entities that identify and investigate fraud.  ZPICs are responsible for 
responding to these requests for information and data analysis.  Timeframes for responding to 
requests from OIG and DOJ generally fall into one of two categories:  Priority I and  
Priority II.  Priority I requests are top priority and are required to be fulfilled within 30 days.  
Priority II requests are less critical and are required to be fulfilled within 45 days.  According 
to the PIM, if the requests require that ZPICs access claims history data using Data Extract 
Software (DESY), the Priority I 30-day and Priority II 45-day timeframes do not apply.    
 
Methodology for determining timeliness of ZPICs response to requests for information.  We 
utilized information in the ZPICs quarterly Requests for Information reports and the 
workload narratives to determine the number of OIG and DOJ Priority I and Priority II 
requests received and completed.  To determine timeliness, we calculated the percentage of 
completed requests that exceeded the 30- and 45-day timeframes.  We excluded requests from 
our calculations if they indicated that they required DESY access, because the timeliness 
timeframes do not apply to these requests.  The quarterly reports for ZPIC A included a 
separate category for requests that required DESY access; quarterly reports for ZPIC B did 
not.  Therefore, we needed to rely solely on the comments in the workload narratives for ZPIC 
B to determine whether the requests required DESY access.  However, because this ZPICs 
narratives may not have identified all DESY requests, our calculations may have included 
some requests that required DESY access.   
 
Table B-7 presents the total number of requests for information received by the ZPICs during 
their first year of operation by the source of the request.  Table B-8 shows the results of our 
analysis of the timeliness of ZPICs response to OIG and DOJ requests.   
 
Table B-7:  Requests for Information Received by ZPICs  
  OIG/DOJ  Other Entities  Total 
ZPIC A  441  75  516 
ZPIC B  429  8  437 
     Both ZPICs  870  83  953 
Source:  OIG analysis of ZPICs Requests for Information workload data, February 1 through October 31, 2009.  
 
   
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A P P E N D I X ~ B  
 
Table B-8:  Timeliness of ZPICs Completion of OIG and DOJ Requests 
for Information 
Percentage of Priority I Requests  Percentage of Priority II Requests 
That Exceeded 30-Day Timeframe  That Exceeded 45-Day Timeframe 
 
ZPIC A  10%  28% 
ZPIC B  34%  19% 
     Both ZPICs  23%  23% 
Source:  OIG Analysis of ZPICs Requests for Information quarterly reports and monthly Requests for Information 
narratives, February 1 through October 31, 2009.  
 
 
ZPICs Overpayments and Other Administrative Actions 
 
ZPICs must take administrative action to prevent and recover inappropriate payments.  
Administrative actions include referrals to the AC/MAC for recovery of overpayments, referrals 
to CMS for recommended payment suspension, referrals to the AC/MAC for recommended 
autodenial or prepayment review edits, referrals to OIG for exclusions, and referrals to CMS or 
OIG for imposition of civil monetary penalties.   
According to the PIM, ZPICs should initially consider less severe administrative actions, such as 
recovery of overpayments and suspension of payments, before making referrals for exclusions or 
civil monetary penalties. 
Table B-9 provides the number and percentage of ZPICs overpayment dollars associated with 
investigations and cases that were referred to the AC/MAC for different types of Medicare 
services.  Table B-10 indicates the percentage of ZPICs overpayment dollars referred that were 
recovered by the AC/MACs.  Table B-11 presents workload data regarding the extent to which 
ZPICs took other administrative actions and provides information regarding administrative 
actions described by ZPICs in response to our survey.   
   
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A P P E N D I X ~ B  
Table B-9:  Overpayments Associated With Investigations and Cases That Were Referred to 
AC/MACs for Different Service Types 
Part A  Part B  DME  HH&H   
Dollars  Percentage  Dollars  Percentage  Dollars  Percentage  Dollars  Percentage  Total  
  
ZPIC A1  $0  0%  $19,505,031  90%  $1,488,324  7%  $722,730  3%  $21,716,085 
ZPIC B2  $8,650,607  16%  $6,404,642  12%  $1,298,623  2%  $36,201,484  69%  $52,555,356 
Bothiii 
ZPICs2  $8,650,607  12%  $25,909,673  35%  $2,786,947  4%  $36,924,214  50%  $74,271,441 
Source:  OIG analysis of CMSs Benefit Integrity workload data, February 1 through October 31, 2009. 
 
1 In response to our survey question that asked ZPICs to describe any issues with their referrals of overpayments to the AC/MACs, ZPIC A noted an issue with its Part A 
hospital overpayment referrals.  The ZPIC stated that it suspended referrals for overpayment collection because the MAC would not process the overpayments that were 
extrapolated by calendar year.  The MAC requested that the overpayments be extrapolated by cost report year, which, in turn, required the ZPIC to reduce the value of the 
overpayments to the actual amount identified.  Given that the Part A dollars referred by ZPIC A is $0, it is possible that the ZPIC referred the reduced overpayment amounts to 
the MAC after our timeframe.   
 
2 Percentages across the row do not total 100 percent because of rounding. 
 
 
Table B-10:  Overpayments Associated With Investigations and Cases  
That Were Referred to and Recovered by AC/MACs 
Number of  Total Dollars  Total Dollars   Percentage 
 
Actions  Referred  Recovered  Recovered   
ZPIC A  35  $21,716,085  $5,789,798  27% 
ZPIC B  52  $52,555,356  $3,713,692  7% 
     Both ZPICs  87  $74,271,441  $9,503,490  13% 
Source:  OIG analysis of ZPIC survey responses and CMSs Benefit Integrity Workload data, February 1 through  
October 31, 2009. 
 
 
   
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A P P E N D I X ~ B  
Table B-11:  Administrative Actions Initiated by ZPICs 
 
ZPIC A  ZPIC B  Both ZPICs 
Payment Suspensions Submitted to CMS1  13  13  26 
Payment Suspensions Denied by CMS  0  1  1 
Providers Referred to OIG for Exclusion2  0  0  0 
Providers Referred to CMS or OIG for Civil 
Monetary Penalties2  0  0  0 
New Autodeny Edits Recommended3  0  3  3 
Prepay Claims Denied  40,601  42,012  82,613 
Dollar Amount of Prepay Claims Denied  $20 million  $12 million  $32 million 
Source:  OIG analysis of CMSs Benefit Integrity workload data, February 1 through October 31, 2009. 
 
1ZPIC A noted that it required some training from CMS to ensure it provided the necessary information and handled the 
suspensions correctly.  ZPIC B noted that it needed to receive authorization from CMS before the payment suspension 
could be implemented and that there have been instances in which authorization was not provided timely and the provider 
was issued the money.  ZPIC B reported that it has worked with CMS to take steps to achieve a faster suspension approval 
time. 
 
2One ZPIC noted that very few of these actions have been referred for many years. 
 
3ZPIC A described a barrier to tracking the savings from autodeny edits.  The ZPIC explained that no report is available from 
the MACs to enable the ZPIC to identify the savings resulting from autodeny edits.  ZPIC B reported that its concern with 
autodeny edits is the ability of the MAC to implement the edits because of system limitations.  
 
 
   
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Agency Comments 
("'w.~ 	
DEPARTMENT OF HEALTH & HUMAN SERVICES 
\,~ 
Administrator 
Washlnglon. DC 20201 
SEP 3 0 2011
DATE: 
TO: 	 Daniel R. Levinson 

Inspector Oeneral 

FROM: 	 Donald M. Berwick, M.D. 

Administrator 

SUBJECT: 	 Office ofInspector Oeneral (010) Draft Report: "Zone Program Integrity 
Contractors' Data Issues Hinder Effective Oversight" (OEI-03-09-00520) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office ofIn.'1pector General (010) draft report entitled, "Zone Program Integrity 
Contractors' Data Issues Hinder Effective Oversight." The purpose of this report was to assess 
CMS' oversight of the Zone Program Integrity Contractors (ZPIC), understand the extent to 
which ZPICs perfonned program integrity activities, detennine the extent to which CMS uses 
program integrity workload statistics in ZPIC performance evaluations, and to identify any 
barriers encountered by ZPICs in perfonning their Medicare program integrity activities. 
In 2008, CMS embarked on a neW program integrity strategy by replacing Program Safeguard 
Contractors (PSCs) with ZP[Cs, which will perform Parts A and B program integrity work in 
seven newly established geographical zones. This new strategy will result in new jurisdictions 
with responsibility for all four claim types: Part A, Part B, durable medical equipment (DME), 
and home health and hospice (HH&H). As of August 2011, CMS has awarded six of the seven 
ZPIC contracts. However, the most recent award is currently under protest; therefore, only five 
of the seven ZPTCs are fully operational at this time. 
The OIG's report was limited to the first two ZPIC awards, Zones 4 and 7, because (hey were the 
only ZPICs thai had completed a full contract year at the time of the OIG's report. CMS concurs 
with some of {he findings that OrG identified in this report and has taken measures to address 
these issues. These include having the CMS Analysis, Reporting, and Tracking System (CMS 
ARTS) contractor fix the errors in the formulas for the total number of new investigations 
originating from reactive sources and the total number ofcases referred originating from reactive 
sources. 
The 010 also indicated that CMS' performance evaluations ofZPICs contained few workload 
statistics. CMS has determined that workload statistics are not the most accurate measure of 
performance evaluations, because the contractors do not have control over the workload assigned 
to them. Instead, CMS uses many other deliverables in the CMS ARTS, such as the monthly 
OEI030900520  ZONE PROGRAM INTEGRITY CONTRACTORS' DATA ISSUES HINDER EFFECTIVE OVERSIGHT  32    
   
A P P E N D I X ~ C  
   
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A P P E N D I X ~ C  
 
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A P P E N D I X ~ C  
 
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A P AP EC NK DN IOX W~ LC E  D G M E N T S  
 
 
This report was prepared under the direction of Robert A. Vito, Regional 
Inspector General for Evaluation and Inspections in the Philadelphia 
regional office, and Linda M. Ragone, Deputy Regional Inspector 
General. 
Tara Bernabe served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Philadelphia 
regional office who contributed to the report include Maria Johnson, 
Ashley Robin, and Sunil Patel; central office staff who contributed 
include Scott Manley.   
 
 
  OEI-03-09-00520  ZONE PROGRAM INTEGRITY CONTRACTORS DATA ISSUES HINDER EFFECTIVE OVERSIGHT  36   
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.