- CMS Medicare Advantage encounter data largely lacks National Provider Identifiers (NPIs) – an essential tool for safeguarding fraud — for providers who order certain equipment, according to a report from the HHS Office of Inspector General.
- Unlike Medicare fee-for-service programs, MA programs aren't required by CMS to submit NPIs for ordering providers on records for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) and for laboratory, imaging and home health services, though almost all have the ability to do so, the report posted Tuesday concluded.
- OIG found 60% of the 2018 MA encounter records for DMEPOS and for laboratory, imaging and home health services were missing an NPI for an ordering provider. The watchdog recommends CMS require Medicare Advantage organizations (MAOs) to submit ordering provider NPIs for these types of items and services. CMS said it agreed with the recommendation in its response to the report.
MA fraud is not uncommon — The U.S. Department of Justice recently sued Cigna, alleging it falsified the health conditions of its MA plan members to coax CMS into making larger payments to the insurer on behalf of beneficiaries, totaling nearly $1.4 billion in overpayments.
Of more than $3 billion recovered by the federal government in fiscal year 2019 from fraud and false claims, 87% involved the healthcare industry, according to DOJ.
In Medicare-fee-for-service programs, CMS uses NPIs for physicians and other practitioners who order DMEPOS, clinical laboratory services, imaging services and home health services to catch inappropriate billing and ordering patterns.
MAOs, which cover a third of Medicare beneficiaries, already collect some of the information. But most don't submit it to CMS because they're not required to do so, even though the items and services are at high risk for fraud, the OIG report found.
OIG analyzed 2018 MA encounter data from CMS' repository in February and also sent a survey to a random sample of MAOs, garnering responses from 179.
Of those MAOs, 58%, or 103 organizations, reported that suppliers or providers of such services submit an ordering provider NPI on at least half of MA encounters. Of those 103, just 25 included ordering provider NPIs on at least half of their records in 2018 encounter data.
To ensure better oversight and prevent fraud, OIG recommends CMS make the ordering provider NPI a required element for encounter data in MA programs, just like Medicare fee-for-service programs. CMS concurred with the general recommendation, but didn't agree with an OIG suggestion it reject any encounter records that contain a provider NPI that is not valid and active in the current provider registry.