Medicare Advantage insurers seldom include identification numbers for clinicians who order certain medical services in the patient records they submit to CMS, the HHS Office of Inspector General found.
According to a report issued Wednesday, 60% of 2018 Medicare Advantage encounter records for durable medical equipment, prosthetics, orthotics and supplies, clinical laboratory, imaging, and home health services were missing a national provider identifier for an ordering clinician.
That's largely because CMS does not require Advantage insurers to submit provider identifiers, even though most insurers already collect that information, according to OIG. The lack of national provider identifier, or NPI, for the ordering provider hinders the federal government's ability to sniff out questionable billing and ordering practices and other Medicare Advantage fraud, OIG concluded in its report.
"It's a problem to not have (NPIs) because if CMS and OIG have them, people fighting fraud can use them as part of their analyses to identify actual or potential payment errors or fraud," said Joanna Bisgaier, deputy regional inspector general in Philadelphia who co-authored the report.
While CMS agreed with OIG's recommendation that it should require Medicare Advantage insurers to submit national provider identifiers for certain services, it said enforcing the requirement by rejecting encounter records without an identifier would be "premature."
In the traditional fee-for-service Medicare program, CMS requires provider identifiers for ordering providers on claims for durable medical equipment and lab, imaging and home health services, and it doesn't pay those claims unless if that identifier is missing.
The Medicare Advantage program, which serves more than a third of Medicare beneficiaries, is treated differently. Instead of sending CMS claims, Advantage insurers submit encounter data, which is detailed information created by healthcare providers about patients' medical diagnoses and treatment. The agency uses the data to calculate the risk of each Advantage enrollee and adjust insurer payments to reflect that risk.
HHS OIG said it focused its analysis on durable medical equipment and lab, imaging and home health services because those items and services are vulnerable to fraud. A previous analysis by OIG found that provider identifiers were missing from 63% of Medicare Advantage encounter records in the first quarter of 2014 for these items and services.
The data hasn't changed much since then. And while CMS at the time of the last review said insurers don't collect identifiers for ordering clinicians, the latest OIG report shows that's not the case.
OIG found that identifiers for ordering clinicians were absent from 71% of records for durable medical equipment, prosthetics, orthotics, and supplies, 62% of records for lab services, and 58% of records for imaging services. Encounter data for home health services was missing a provider identifier 17% of the time, though the authors noted that they may have overestimated the prevalence of identifiers on home health records.
The report further found that submitting the identifiers may not be a heavy lift for most insurers. OIG surveyed about 180 Advantage insurers online and found that nearly all of them said their data systems can receive and store provider identifiers when physicians submit them. What's more, most insurers—58%—responded that providers of equipment, lab services and imaging services submit an identifier for an ordering provider on at least half of claims or encounter data.
About half of Advantage insurers with other lines of business, such as Medicaid or commercial plans, require providers to submit identifiers on claims and encounter records, the report said. Four in 10 insurers said that collecting identifiers for ordering clinicians is important for preventing fraud.
In a January memo, CMS acknowledged that the lack of identifiers for ordering physicians hinders program integrity. It told OIG in August that it is exploring how to implement such a requirement but said it's too early to enforce it.
"We appreciate that they must first require ordering provider NPIs before implementing the reject edits," Bisgaier said. "However, in order to use the ordering provider NPIs for preventing and detecting fraud and abuse, it's important that CMS eventually implement those reject edits to ensure that the NPIs are present and valid when required."
