U S Government Accountability Office

Medicare Program Integrity U S Government Accountability Office

" GAO has designated Medicare as a high-risk program, in part because its size and complexity make it particularly vulnerable to fraud. To help detect and prevent potential Medicare fraud, CMS-the agency within the Department of Health and Human Services (HHS) that administers the Medicare program-contracts with ZPICs. These contractors are to identify potential fraud, investigate it thoroughly and in a timely manner, and take swift action, such as working to revoke suspect providers' Medicare billing privileges and referring potentially fraudulent providers to law enforcement. GAO examined (1) ZPIC contract costs and how ZPICs use those funds, (2) the results of ZPICs' work, and (3) the results of CMS's evaluations of ZPICs' performance and aspects of CMS's evaluation practices. To do this, GAO examined ZPIC funding, contracts, and related documents; data on ZPICs' workloads, investigations, and results; and CMS evaluations of ZPICs as well as federal standards for performance measurement. GAO also interviewed CMS and ZPIC officials. "