The HHS Office of Inspector General (OIG) is asking CMS to establish additional performance standards for contractors to ensure they're focused on high-risk providers in fraud-prone areas.
 
The standards "could guide contractors in focusing their activities on specific types of providers that are exhibiting high levels of potential fraud and that need particular oversight emphasis, such as HHAs," the Dec. 20 report states.
 
CMS concurred with the recommendation, noting that screening regulations which took effect in 2011 and the implementation of predictive modeling tools have gone some way towards better identifying fraudulent providers. CMS also says it's in the process of revising the zone program integrity contractors' (ZPICs) statement of work "to clarify the processes to be used in this work."
 
The OIG also found that CMS failed to act on several recommendations to revoke billing privileges for agencies. In its response, CMS says it has established "a set of guidelines" to ensure such recommendations are addressed quickly. CMS also notes that it has established edits to ensure that agencies whose billing privileges have already been revoked won't continue to receive payments.
 
The review period covered in the report is January through October 2011. During that period, the OIG found that Medicare administrative contractors (MACs) NHIC and Palmetto collectively prevented some $275 million in improper payments and referred 14 agencies for potential fraud. However, the four ZPICs reviewed by the OIG "varied substantially in their efforts to detect and deter fraud," according to the report. For example, while one of the ZPICs referred 19 agencies for further action, another ZPIC referred 147 agencies during the same period.
 
For additional analysis and guidance on this report, see the Jan. 7 issue of HHL.