Medicare Advantage Organizations Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity

WHY WE DID THIS STUDY

National Provider Identifiers (NPIs) for ordering providers are essential for safeguarding the program integrity of what we refer to in this issue brief as high-risk services in Medicare-i.e., durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS); clinical laboratory services; imaging services; and home health services. For these services, NPIs are critical for identifying patterns of inappropriate billing and ordering among providers and investigating fraud and abuse. Both CMS and 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. 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.

HOW WE DID THIS STUDY

To determine the extent to which MAOs conducted program integrity oversight activities by using ordering NPIs submitted by providers and/or suppliers of high-risk services, we administered an online survey to a stratified random sample of 200 MAOs from February to March 2020. We received responses from 179 MAOs. This is the second OIG issue brief that analyzes data from this survey; the first was released in August 2020 and focused on the extent to which MAOs collected ordering NPIs and submitted these identifiers to CMS's MA Encounter Data System.

WHAT WE FOUND

Almost half of the MAOs that lack ordering NPIs on at least some MA encounter records raised concerns that this hinders their data analysis for program integrity. Among MAOs that collect any ordering NPIs, most use these NPIs to conduct oversight activities-such as analyses that detect potential fraud schemes-but one in five of these MAOs does not perform program integrity oversight using ordering NPIs, despite having the data to do so. Furthermore, when MAOs collect ordering NPIs on MA encounter records, most do not validate these NPIs against CMS's NPI registry. These findings indicate that there are unrealized opportunities for MAOs to use ordering NPIs to protect the MA program against fraud and abuse.

WHAT WE RECOMMEND

OIG recommends that CMS encourage MAOs to perform program integrity oversight using ordering NPIs. CMS neither concurred nor nonconcurred with this recommendation and stated that it would consider whether additional education is needed for MAOs regarding the role that ordering NPIs can play in program integrity oversight.