Medicare Benefit Integrity Contractor Activities

Dianne De La Mare

The US Department of Health and Human Services (HHS), Office of Inspector General (OIG), has published a report, Medicare Benefit Integrity Contractors’ Activities in 2012-2013: A Data Compendium, focusing on the Program Safeguard Contractor (PSC), Zone Program Integrity Contractor (ZPIC) and the National Benefit Integrity Medicare Drug Integrity Contractor (MEDIC). According to the report, some workload results, such as the number of proactive projects started and the number of revocations recommended for contractors increased overall from 2012-2013, while others, such as the number of cases referred to law enforcement, decreased.

While increases and decreases vary from year to year and may be caused by reasonable shifts in workload priorities, OIG believes the Centers for Medicare & Medicaid Services (CMS) should examine these changes to ensure that they are in alignment with the agency’s integrity goals.

CMS concurs with OIG’s recommendation; however, to address workload variations, CMS 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 in a unified manner. CMS will also provide guidance to align all Medicare contractors with clearly defined workload definitions.