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CMS's Encounter Data Lack Essential Information That Medicare Advantage Organizations Have the Ability to Collect


National Provider Identifiers (NPIs) for physicians and nonphysician practitioners who order and/or refer services (ordering providers) are essential for safeguarding the program integrity of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); clinical laboratory services; imaging services; and home health services in Medicare. NPIs are critical for identifying inappropriate billing and ordering patterns among providers and investigating fraud and abuse. Both CMS and 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 Medicare Advantage (MA) encounter records for DMEPOS and for laboratory, imaging, and home health services, and recommended that CMS establish and enforce requirements for MA Organizations (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.


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.


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.


OIG recommends that CMS require MAOs to submit the ordering provider NPI on encounter records for DMEPOS and for laboratory, imaging, and home health services; and establish and implement "reject edits" that (1) reject encounter records in which the ordering provider NPI is not present when required and (2) reject encounter records that contain an ordering provider NPI that is not a valid and active NPI in the NPPES registry. CMS concurred with the first recommendation but did not concur with the second recommendation.