CMS’s encounter data lack essential information that Medicare Advantage organizations have the ability to collect
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Issue brief (United States. Department of Health and Human Services. Office of Inspector General)
- Contributor(s):
- United States. Department of Health and Human Services. Office of Inspector General. Office of Evaluation and Inspections. issuing body.
- Publication:
- Washington, D.C. : U.S. Department of Health and Human Services, Office of Inspector General, August 2020
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Data Management -- legislation & jurisprudence Fraud -- prevention & control Government Regulation Medicare Part C -- organization & administration Records -- statistics & numerical data United States United States. Department of Health and Human Services
- Genre(s):
- Technical Report
- Abstract:
- Why OIG Did This Review. NPIs for ordering providers are essential for safeguarding the program integrity of DMEPOS, clinical laboratory services, imaging services, and home health services in Medicare. (In this issue brief, we refer to clinical laboratory services as laboratory services.) For these items and services, NPIs are critical for identifying inappropriate billing and ordering patterns among providers and investigating fraud and abuse. Both the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) rely on NPIs for ordering providers to conduct oversight and pursue fraud investigations. Prior OIG work found that ordering provider NPIs were absent from 63 percent of MA encounter records for DMEPOS and for laboratory, imaging, and home health services, and recommended that CMS establish and enforce requirements for MAOs to submit ordering provider NPIs for these types of items and services. Findings from our survey of MAOs may be useful as CMS weighs the program integrity benefits of requiring NPIs for ordering providers against the potential burden that MAOs would experience from establishing and enforcing these requirements. How OIG Did This Review. To determine the extent to which MAOs submitted ordering provider NPIs on encounter records for DMEPOS and for laboratory, imaging, and home health services, we extracted and analyzed 2018 MA encounter data from CMS’s Integrated Data Repository in February 2020. We also sent an online survey to a stratified random sample of 200 MAOs. We received responses from 179 MAOs. What OIG Found. CMS’s MA encounter data continue to lack ordering provider NPIs on records for DMEPOS and for laboratory, imaging, and home health services. However, we found that almost all MAOs have data systems that are able to receive and store these NPIs when providers submit them to MAOs on claims or encounter records. In addition, a substantial portion of MAOs reported that providers are already submitting the ordering provider NPIs on claims or encounter records for DMEPOS, laboratory services, and imaging services. Further, a majority of MAOs require NPIs to be submitted for their other lines of business (such as commercial and private health insurance, Medicaid, and the Children’s Health Insurance Program). Finally, almost half of MAOs believe that NPIs for ordering providers are critical for combating fraud.
- Copyright:
- The National Library of Medicine believes this item to be in the public domain. (More information)
- Extent:
- 1 online resource (1 PDF file (16 pages))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 9918282381406676 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/9918282381406676