Conflicts and Financial Relationships Among Potential Zone Program Integrity Contractors

WHY WE DID THIS STUDY

CMS uses Zone Program Integrity Contractors (ZPIC) to perform program integrity activities designed to fight fraud, waste, and abuse in the Medicare program. Conflicts of interest among ZPICs could compromise CMS's efforts to protect the program. CMS requires companies that submit proposals for ZPIC contracts (offerors) and their subcontractors to (1) disclose information about any business or contractual relationships that may present conflicts and (2) provide a strategy to mitigate all conflicts of interest that may compromise the ZPICs' impartiality in conducting their work.

HOW WE DID THIS STUDY

We reviewed conflict-of-interest information for 18 offerors and 85 subcontractors. We also conducted a structured interview with CMS staff to determine how CMS addresses conflicts of interest among offerors. We determined whether offerors and subcontractors provided CMS all the information required for their reported conflicts and financial interests.

WHAT WE FOUND

Offerors and their subcontractors often had business and contractual relationships with CMS and with other offerors, but rarely considered them to be actual conflicts. They reported having relationships with CMS or contractors of CMS that provide Medicare Parts C and D plans, claims processing, program integrity, and/or quality improvement services. Offerors, subcontractors, and CMS identified 1,919 business and contractual relationships as possible conflicts and 16 as actual conflicts. CMS does not have a written policy for reviewing conflict and financial interest information submitted by offerors, and submitted information was not always consistent or complete. Specifically, some offerors and subcontractors failed to provide all the requisite information regarding financial interests in other entities.

WHAT WE RECOMMEND

To encourage an environment of transparency and accountability among contractors, we recommend that CMS: (1) provide clearer guidance in the Request for Proposals to offerors and subcontractors regarding which business and contractual relationships should be identified as actual conflicts and which should be identified as possible conflicts; (2) require offerors and subcontractors to distinguish those business and contractual relationships that they deem to be actual conflicts from those they deem to be possible conflicts; (3) state whether offerors and subcontractors need to report income amounts, periods of performance, and types of work performed for their contracts with CMS and income amounts generated from key personnel's other employment; (4) create a standardized format for reporting information in the Organizational Conflict of Interest Certificate and require its use by offerors and subcontractors; and (5) develop a formal, written policy outlining how conflict-of-interest information provided by offerors should be reviewed by CMS staff. CMS partially concurred with our first and second recommendations and fully concurred with the remaining recommendations.