Medicare Benefit Integrity Contractors' Activities in 2012 and 2013: A Data Compendium

This report provides a visual representation of data on the workload activities of Medicare benefit integrity contractors in calendar years 2012 and 2013. The report allows for a quick comparison of workload statistics across the 2 years, across contractors, and across Medicare programs and provides a baseline for reviewing contractors' quantitative results over time. The report provides descriptive information about the changes that occurred from 2012 to 2013 as well as the variation among contractors' workload statistics. However, the report does not examine the underlying causes of those changes or variations. The contractors include Program Safeguard Contractors, Zone Program Integrity Contractors, and the National Benefit Integrity Medicare Drug Integrity Contractor. Past OIG work has shown substantial variation among benefit integrity contractors with respect to the number of investigations they started and the number of cases that they referred to law enforcement. It has also shown that the contractors made limited use of proactive methods to identify potential fraud and abuse; and that they did not report workload statistics in a uniform manner. In addition, previous OIG work has identified anomalies in contractors' workload statistics, which may highlight issues with the CMS's oversight of these contractors. Although we have conducted previous studies on these individual contractor types, this is the first report to provide the results of benefit integrity activities across all of these contractors. Figure 1 provides a comparison of the results of benefit integrity contractors' activities between 2012 and 2013.

We found variation in the level of benefit integrity activities across contractors in 2012 and 2013, even when we accounted for differences in the size of contractors' oversight responsibility and the amount paid for their contracts. Although there may be valid reasons for the variation among contractors, we believe that CMS should examine the variation and, if necessary, take steps to address poor performance, share best practices, or clarify workload definitions. In addition, while increases and decreases in workload statistics from year to year may be caused by reasonable shifts in workload priorities, we believe that CMS should examine the workload statistic changes to ensure that they align with its benefit integrity goals. Given that the work of the benefit integrity contractors-as well as CMS's oversight of these contractors-is vital to the integrity of the Medicare program, we recommend that CMS: (1) examine trends in workload statistics, determine the causes for the increases and decreases in workload statistics across years, and determine whether these changes align with CMS's benefit integrity goals; and (2) examine the variation in workload statistics among benefit integrity contractors; and, as appropriate, identify performance issues that need to be addressed, best practices that can be shared, and workload definitions that need to be clarified to ensure that contractors report data uniformly and in the way CMS intends. CMS concurred with both of these recommendations.