Wrong addresses, telephone numbers and licensing
information for physicians have been found throughout the enrollment
systems that Medicare uses to approve pay for beneficiary services,
according to federal auditors.
An estimated 58% of
enrollment records in the Provider Enrollment, Chain and Ownership
System were inaccurate, and 48% of records in the National Plan and
Provider Enumeration System had errors, the Dept. of Health and Human
Services Office of Inspector General stated in a report published May
28. The records also were inconsistent between the two systems, with
nearly all records for health professionals in PECOS and NPPES
containing mismatched information in 2010.
“The
results of our analyses show that NPPES and PECOS data are not reliable
independently or even when combined,” the OIG stated.
Work
already is under way to fix NPPES, which physicians use to obtain
national provider identifiers that allow them to contract with public
and private payers, and PECOS, which allows physicians to participate in
Medicare. The Centers for Medicare & Medicaid Services has led a
massive effort to verify and correct errors found in PECOS, which
contains the records of 1.5 million physicians, other health care
professionals and suppliers, a CMS spokesman said. About 460,000 records
have been revalidated to date, resulting in 160,000 enrollments being
deactivated and 14,000 being revoked.
“We take this
report very seriously and are committed to ensuring the integrity of the
Medicare program through effective monitoring of provider enrollment
data,” the spokesman said.
The enrollment sweep has
led to 10,041 physician billing privileges being revoked and 83,188
being deactivated. A felony record or noncompliance with CMS rules can
lead to revocation. Deactivation can involve records for physicians who
go a year or more without billing Medicare for services, among other
situations.
The scope of the inaccuracies
Medicare began using PECOS in 2002. The agency
stores records of everyone with billing privileges in one place in an
effort to ensure integrity in the system. Similarly, NPPES has been used
to centralize unique identifiers for 2.8 million health care
professionals and 913,000 health care organizations with IDs.
At
first, physicians would fill out paper applications to obtain NPIs and
enroll in Medicare. Forms would be sent to contractors who manually
entered information into the systems. Paper applications still are
accepted, but these tasks also can be completed online.
The
errors found in the records could be the result of simple clerical
mistakes introduced either by the practices or the contractors, said
Allison Brennan, a senior advocacy adviser with MGMA-ACMPE, which
represents practice managers. Physicians and others participating in
Medicare also are responsible for reporting address changes and other
revised information within 30 to 90 days, depending on the type of
change. These updates must be recorded in each system separately.
“It's unfortunate that these systems don't talk to each other,” Brennan said.
Data
in the two systems were inconsistent for 97% of records sampled by the
OIG. An incorrect or mismatched address was the source of the most
inconsistencies.
In NPPES, about a third of the
records had the wrong mailing addresses, and about a third had the wrong
practice addresses. The mailing addresses were incorrect in nearly half
of PECOS records. Other mistakes included erroneous credentials,
licenses and surnames.
Even if physicians are being
paid for Medicare services, inaccurate addresses still can have negative
consequences. Many communications from CMS, such as claims remittances,
are sent electronically, but the agency relies on mail for some
communications. One example is the enrollment revalidation effort
itself, during which requests for verifying records are being sent to
the mailing and practice addresses on file.
Revalidation
requests must be completed within 60 days, or the physicians and health
professionals will have their billing privileges deactivated, CMS
stated. A physician who has his or her record deactivated can restore it
by filing an enrollment application.
CMS is
developing additional mechanisms to protect Medicare program integrity.
An automated screening system would validate information such as
licensure and exclusion status due to an adverse action taken against a
health professional, CMS Administrator Marilyn Tavenner wrote in a memo
responding to the OIG report. But that effort's scope is limited.
“CMS'
new automated provider-screening tool has the potential to improve the
accuracy of PECOS data,” the OIG stated. “However, it does not reduce
the risk of fraudulent NPI enumeration and will not improve NPPES data
accuracy.”
Mistakes duplicated online
Incorrect addresses found on the Internet
federal directory of Medicare's participating physicians are connected
to errors in PECOS. Physicians and organized medicine groups have
expressed concerns about the accuracy of Medicare's Physician Compare
since the website launched in December 2010.
Congress,
through the Affordable Care Act, required CMS to develop the site. It
provides beneficiaries and their caregivers with information about
physicians in Medicare, such as their participation in the physician
quality reporting system and whether they accept new patients.
“It
is critical that data in PECOS be accurate and up to date to ensure the
data on Physician Compare are also accurate and up to date,” CMS stated
in the 2013 Medicare fee schedule. “CMS is evaluating other options for
physicians, health professionals and group practices to update their
information, and is looking at other available data sources to validate
PECOS data to further improve accuracy as we continue to improve the
data presented on Physician Compare.”
A physician
can correct an address error found on the website by revising his or her
PECOS record. The agency will repopulate information online
periodically.
The American Medical Association
has advocated for changes to Physician Compare, which is scheduled for
an upgrade later in 2013. New functionality is expected to include the
ability to search for a physician to treat a specific condition or organ
system.
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