By Susan L. Smith, JD, MA
The Office of Inspector General found that encounter data for Medicare Advantage Organizations (MAOs) continue to lack ordering provider National Provider Identifiers (NPIs) on records.
The Office of Inspector General (OIG) has recommended that CMS require Medicare Advantage Organizations (MAOs) to submit ordering providers National Provider Identifier (NPIs) on encounter records for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); clinical laboratory services; imaging services; and home health services for Medicare Advantage enrollees. The OIG explained that NPIs for ordering providers are critical for identifying inappropriate billing and ordering patterns among providers and investigating fraud and abuse. Although CMS does not require MAOs to submit the ordering provider NPI, the OIG found that most MAOs have data systems that are able to receive and store NPIs when providers submit them on claims or encounter records and many reported that providers are submitting the ordering provider NPIs on claims or encounter records for those services (OIG Issue Briefv, No. OEI-03-19-00430, August 25, 2020).
CMS current status for ordering provider NPI. Although CMS does not pay claims for services for DEMPOS, laboratory, imaging and home health services in Medicare fee-for-service unless the claim has a valid NPI for an ordering provider, it has not designated the ordering provider NPI as required data element for encounter data under the MA program. Because CMS has not required the ordering provider NPI for MA encounter data on these services, it lacks information to identify fraud in these high-risk areas. In January 2020, CMS acknowledged that a lack of ordering provider information in encounter records for these services hinders potential program integrity efforts.
OIG’s review and findings. OIG extracted and analyzed 2018 MA encounter data from CMS’ Integrated Data Repository in February 2020to determine the extent that MAOs submitted ordering provider NPIs on encounter records for DEMPOS, laboratory, imaging, and home health services. OIG also sent an online survey to a stratified random sample of 200 MAO’s and received responses from 179 MAOs. The OIG found that in addition to having data systems that are able to receive and store ordering provider NPIs when providers submit them on MA claims or encounter data, almost half of MAOs reported that providers submit NPIs for ordering providers on at least half of the MA claims and encounter data for DMEPOS, laboratory services, and imaging services. Moreover, many MAOs believe that ordering provider NPIs are a critical piece for preventing and detecting fraud and abuse. In addition, some MAOs require providers to submit ordering provider NPIs on claims and encounter data for other lines of business.
OIG recommendations. The OIG previously found that ordering provider NPIs were not included in 63 percent of MA encounter records for DMEPOS and laboratory, imaging, and home health services. At that time, OIG recommended that CMS require MAOs to submit ordering provider NPIs for these items and services. In its current report, the OIG continued to recommend that CMS (1) require MAOs to submit the ordering provider NPI on encounter records for DMEPOS, laboratory, imaging, and home health services; and (2) establish and implement reject edits that reject encounter records when the ordering provider NPI is not present when required and reject encounter records that contain an ordering provider NPI that is not valid and active in the National Plan and Provider Enumeration System Registry. CMS concurred with the first recommendation but did not concur with the second stating that MAOs do not always require ordering provider NPIs on the claims that providers submit to them and, therefore, MAOs would not have these NPIs available to submit to CMS. CMS has not yet implemented OIG’s recommendations.
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