Kusserow’s Corner: OIG Finds Problems With Provider Enumeration and Enrollment Data

The Office of Evaluation and Inspections (OEI) of the HHS Office of Inspector General (OIG) released a report that includes findings that provider data in two Medicare databases are often inaccurate and that Medicare Administrative Contractors (MACs) are ineffectively employing oversight. The OIG surveyed a random sample of individual Medicare providers to determine the accuracy of the provider information stored in the National Plan & Provider Evaluation System (NPPES) and the Provider Enrollment, Chain, and Operating System (PECOS).  Health care provider information, including providers’ unique National Provider Identifiers (NPIs), is maintained in the NPPES. To enroll in Medicare, providers must supply their NPIs and other information to CMS to be entered into PECOS.  Accurate, complete, and consistent provider data in NPPES and PECOS help to ensure the integrity of all health care programs.  The OIG found that problems cited in previous reports regarding CMS’s oversight of provider data are continuing.  These weaknesses are leading, in some cases, to improper Medicare payments to fraudulently enrolled providers.

The OIG found provider data in NPPES and PECOS were often inaccurate, occasionally incomplete, and generally inconsistent between the two databases. In NPPES, provider data were inaccurate in 48 percent of records and complete for nearly all required variables, but incomplete for conditionally required variables in 9 percent of records. In PECOS, provider data were inaccurate in 58 percent of records and incomplete in almost 4 percent. Additionally, provider data were inconsistent between NPPES and PECOS for 97 percent of records. Addresses, which are essential for contacting providers and identifying trends in fraud, waste, and abuse, were the source of most inaccuracies and inconsistencies. Finally, CMS did not verify most provider information in NPPES or PECOS.

Inaccurate, incomplete, and inconsistent provider data, coupled with insufficient oversight, place the integrity of the Medicare program at risk and present vulnerabilities in all health care programs. The OIG made three major recommendations, all of which were concurred with by CMS:

  1. CMS should require MACs to implement program integrity safeguards for Medicare provider enrollment as established in the Program Integrity Manual (PIM). CMS noted that it has issued supplementary enrollment guidance in the PIM to the MACs, but the results of the OIG study suggest they may not understand them.   CMS was urged to move to further clarification with the MACs.
  2. Additionally, CMS should require more verification of NPPES enumeration and PECOS enrollment data.  CMS stated it has mechanisms under development to further verify accuracy of the data.
  3. CMS should detect and correct inaccurate and incomplete provider enumeration and enrollment data for new and established records.   CMS responded that it has plans to use a new Automated Provider Screening tool to identify changes to provider data in PECOS and identify specific providers to revalidate more frequently.

Richard P. Kusserow was the DHHS Inspector General for over eleven years.  He is the author of nine books related to compliance.  He is the founder and CEO of Strategic Management, a firm that has been providing specialized compliance advisory services since 1992 to 2,000 clients. For more information, contact him at rkusserow@strategicm.com.

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