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Recommendation Followup: Ensuring that MAOs Submit Rendering Provider Identifiers for Applicable Encounter Records

Announced on  | Last Modified on  | Project Number: OEI-03-25-00440
Status
Active
Agency
Centers for Medicare and Medicaid Services

OBJECTIVE

A rendering provider National Provider Identifier (NPI) is a critical data element on Medicare Advantage (MA) encounter records that: (1) identifies the individual who performed a health care service and (2) enables oversight entities and MA organizations (MAOs) to identify individuals who may pose a risk to Federal funds and enrollee safety. CMS stated that it requires MAOs to submit the rendering provider NPI when it differs from the billing provider NPI. A 2018 OIG report found that rendering provider NPIs were missing on 13 percent of 2014 MA encounter records for outpatient evaluation and management services in which the billing provider was an organization (e.g., a clinic or a provider group). We continue to be concerned that the omission of rendering provider NPIs may impede oversight and program integrity activities. This new evaluation will review 2024 encounter data to determine whether MAOs are submitting rendering provider NPIs.

TIMELINE

  • November 15, 2025
    Announced
  • Today
    Office of Evaluation and Inspections In-Progress
  • Est FY2027
    Estimated Fiscal Year for Project Completion
Work Plan Type
Office of Evaluation and Inspections
HHS Agencies
Centers for Medicare and Medicaid Services
Issue Areas
Financial Stewardship Managed Care
Target Groups
Elderly
Financial Groups
-