Medicare Advantage organizations are missing opportunities to use ordering provider identifiers to protect program integrity

Medicare Advantage organizations are missing opportunities to use ordering provider identifiers to protect program integrity

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, April 2021
Language(s):
English
Format:
Text
Subject(s):
Data Analysis
Fraud -- prevention & control
Government Regulation
Medical Order Entry Systems
Medicare Part C -- economics
United States
United States. Department of Health and Human Services
Genre(s):
Technical Report
Abstract:
This issue brief summarizes results from our evaluation of Medicare Advantage organizations’ (MAOs’) use of National Provider Identifiers (NPIs) for physicians and nonphysician practitioners who order and/or refer high-risk services—i.e., durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); clinical laboratory services; imaging services; and home health services—for Medicare Advantage (MA) enrollees. (In this issue brief, we refer to these providers as ordering providers.) Why OIG Did This Review. NPIs for ordering providers are essential for safeguarding the program integrity of high-risk services in Medicare. For these services, NPIs are critical for identifying patterns of inappropriate billing and ordering among providers and investigating fraud and abuse. Both the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) rely on ordering provider NPIs (hereafter ordering NPIs) to conduct oversight and pursue fraud investigations. However, prior OIG work found that these NPIs were largely absent from CMS’s MA encounter data, despite evidence that many MAOs can—and do—already collect this information. (Encounter data are detailed information submitted by MAOs to CMS regarding each service provided to MA beneficiaries.) As a result, OIG recommended that CMS establish and enforce requirements for MAOs to submit ordering NPIs for high-risk services. Findings from this issue brief may be useful as CMS considers requiring MAOs to collect and use ordering NPIs for MAOs’ program integrity oversight activities.
Copyright:
The National Library of Medicine believes this item to be in the public domain. (More information)
Extent:
1 online resource (1 PDF file (14 pages))
Illustrations:
Illustrations
NLM Unique ID:
9918383969906676 (See catalog record)
Permanent Link:
http://resource.nlm.nih.gov/9918383969906676