News: OIG semi-annual report to Congress cites CMS limitations

The Office of the Inspector General (OIG) pointed to deficiencies in CMS’ oversight of Zone Program Integrity Contractors (ZPICs), indicated that Comprehensive Error Rate Testing (CERT) program calculations could be more accurate, and pointed to unaddressed contractor-identified vulnerabilities in its Spring 2012 semi-annual report to Congress.

• “The workload data that CMS uses to oversee ZPICs were not accurate or uniform, and inaccuracies and lack of uniformity in the ZPICs' data prevented us from making a conclusive assessment of ZPICs’ activities. The conditions are serious obstacles to CMS’s oversight of ZPIC operations and effectiveness.”
• “The estimated impact of vulnerabilities, such as those in claims coding and provider identifiers, which contractors reported inconsistently or not at all, was at least $1.2 billion. Only two of the vulnerabilities reported in 2009 had been resolved as of January 2011. Although CMS has procedures to consistently track and review vulnerabilities, it lacks procedures to ensure that vulnerabilities are resolved.”
• “If [a] CERT statistical contractor had included overturned CERT claim payment denials in its error rate calculations, it would have decreased the estimated value of reported errors for FYs 2009 and 2010 by approximately $2 billion each year.”
• “Additional documentation to overturn the claim payment denials used in the FY 2010 error rate calculation would have reduced the estimate of improper payments for FY 2010 by almost $1 billion.”