HHS OIG Recommends CMS Require NPIs for Ordering Providers


HHS OIG recently updated its Work Plan items with a recommendation to CMS to require MAOs to submit NPIs for ordering providers. The availability of ordering provider identifiers has been an issue in Medicare Advantage encounter data.

In this post, we’ll take a look at the request from HHS Office of Inspector General (OIG), examine some of the reasons why this information would be helpful, and discuss some concerns from payers in regard to the accuracy of CMS encounter data. 

HHS OIG Recommends CMS Requires Ordering Provider Identifiers

In the November 2019 HHS OIG Work Plan, HHS OIG initiated a new study that will help determine “the extent to which MAOs obtain the NPIs of providers who order DMEPOS, clinical laboratory services, imaging services, and home health services for MA enrollees and will determine how MAOs that do not obtain these identifiers are conducting routine monitoring, auditing, and oversight of these types of services.” 

The new study also hopes to provide further clarification on how many Medicare Advantage Organizations (MAOs) voluntarily submit the National Provider Identifiers (NPIs) of providers ordering services to the Center for Medicare and Medicaid Services (CMS). 

Identifying FWA from Medicare Advantage Data 

The Department of Health and Human Services OIG is in charge of protecting the integrity of federal healthcare programs. HHS OIG remains adamant that CMS requires MAOs to disclose NPIs for ordering providers in encounter data records to better identify potential fraud, waste, and abuse (FWA). In previous work, OIG has identified that almost two-thirds of Encounter Data Records (EDR) did not include NPIs for ordering providers

Medicare Advantage (MA) plans have been a heavy focus for HHS OIG because of high enrollment and cost of beneficiaries who are covered through these services. Data shows that as much as one-third of Medicare beneficiaries receive benefits through an MA plan. 

Medicare enrollees generally have the option to receive their benefits through the traditional Medicare fee-for-service program or through private plans. Private insurance companies, known as MA organizations, contract with the Centers for Medicare & Medicaid Services (CMS) under Medicare Part C to provide beneficiaries with private health plan options, including managed care plans. 

In 2012, an HHS OIG Study of Medicare Advantage Organizations’ Identification of Potential Fraud and Abuse was conducted to determine the extent of MA organizations’ efforts to identify and address potential fraud and abuse that are crucial to protecting the integrity of the MA program. This study uncovered many red flags, including provider directory inaccuracies, differences in the way MA organizations defined and detected potential fraud and abuse, corrective actions taken by MAOs, and more. 

What is Medicare Advantage Encounter Data? 

Encounter data is detailed information by healthcare providers that documents both the clinical conditions they diagnose as well as the services and items delivered to beneficiaries for treatment. In 2012, CMS began requiring providers to submit Encounter Data Records. CMS defines encounter data specifically as, “the data necessary to characterize the context and purposes of each item and service provided to a Medicare enrollee.” 

Encounter Data Records (EDRs) are reports from a Medicare Advantage Organization (MAO) or other submitters to CMS about medical items or services a beneficiary received while enrolled in one of the MAO’s plans. CMS expects that MAOs and other entities will submit EDRs for each service or item covered by the health plan and provided to an enrollee, regardless of the payment status of the claim. 

Over the years, the Centers for Medicare and Medicaid Services (CMS) has used MA encounter data for a variety of reasons, including risk adjustment payments, identifying patterns in diagnoses, risk assessments, chart reviews, and calculating risk scores for beneficiaries. The MA encounter data entry process has improved other the years, but problems and inefficiencies still exist in the type of information being provided and incomplete records.

Because of this, HHS OIG still has concerns over how Medicare Advantage Organizations (MAOs) may be taking advantage of unsupported risk-adjusted payments driving improper payments in the Medicare Advantage (MA) program. CMS does not require MA organizations to report the results of their efforts to identify and address potential fraud and abuse incidents. 

Payer Concerns for CMS Risk Adjustment Payments

CMS recently provided notice to Medicare Advantage Organizations, Prescription Drug Plan Sponsors, and Other Interested Parties, announcing proposed changes to the risk adjustment model for CY 2021. The CMS notice explains some of the details surrounding the transition from the Risk Adjustment Payment System (RAPS) to the Encounter Data Processing System (EDPS). Transitioning to a new system has drawn concern from MAOs because of expected reimbursement and revenue challenges. 

In 2016, CMS used encounter data to calculate risk adjustment payments at a level of 10%. For 2021, CMS has proposed to increase the amount of encounter data that will be used to calculate risk adjustment payments to 75%, with the remainder using traditional RAPS data. 

Recent comments from health plans in regard to these changes have described the frustration and concerns about this shift. American Health Insurance Plans wrote that the organization, “continues to have very significant concerns about the expanded use of encounter data for payment purposes given the unresolved operational issues that prevent CMS from generating complete and accurate risk scores and CMS’ open acknowledgment that expanding the use of encounter data will reduce payments.”

Addressing Government Data Inaccuracies with Automated Solutions

At ProviderTrust, we assist healthcare organizations with discovering the most detailed provider information. Our goal is to make healthcare smarter and safer with enhanced provider data and ongoing monitoring solutions. We combine unique provider identifiers such as NPIs, credentials, shared data, and sanction records to create complete-provider profiles. 

This detailed information gives healthcare organizations the necessary tools to make informed decisions, mitigate risk, and reduce issues surrounding recoupment and CMS reimbursement. 

To learn more about who we are or how we can help, please Contact Us today!

Stay Up-to-Date

Subscribe and get the latest news and advice from industry experts delivered straight to your inbox.

Related Resources

Never miss an update

Get the latest healthcare news, advice from industry experts, and all things related to monitoring solutions delivered straight to your inbox.