OIG Study Finds NPPES and PECOS Inaccuracy
June 7, 2013 02:56 PM
The Office of Inspector General (OIG) released a study conducted to evaluate the accuracy of two Centers for Medicare & Medicaid Services (CMS) health care provider databases: National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain and Ownership System (PECOS).
The study was undertaken as a follow-up to previous OIG work that revealed ongoing problems with CMS’s oversight of provider data, sometimes resulting in improper Medicare payments. The results of the OIG analyses showed that NPPES and PECOS data are not reliable independently or even when combined The OIG report can be found here.
OIG Study Objectives
Analysis of provider enumeration data (i.e., from providers’ applications for National Provider Identifiers (NPIs)) and Medicare provider enrollment data maintained CMS for accuracy, completeness, and consistency; and
Analysis of CMS oversight processes for ensuring the accuracy, completeness, and consistency of provider enumeration data and Medicare provider enrollment data.
After review of several data elements in both NPPES and PECOS and interviews with providers, the OIG concluded that “Medicare provider data in NPPES and PECOS were often inaccurate and occasionally incomplete, and were generally inconsistent between the two databases.” They found that NPPES data were inaccurate in 48 percent of records and incomplete for conditionally required variables in 9 percent of records.
In PECOS, provider data were inaccurate in 58 percent of records and incomplete in almost 4 percent. Addresses were the major source of data inaccuracies. However, inaccuracies were also found in other areas, such as license and credential information. Additionally, although no Federal mandate requires that information in NPPES and PECOS be consistent, provider data were inconsistent between NPPES and PECOS for 97 percent of records. More than three out of four providers identified inaccurate data in NPPES or PECOS, and more than one in four providers identified inaccurate data in both NPPES and PECOS.
After interviews with contractors, the OIG also concluded that CMS did not verify most provider information in NPPES or PECOS.
Based on these findings the OIG made the following recommendations to CMS:
Require Medicare Administrative Contractors to implement program integrity safeguards for Medicare provider enrollment.
Require more verification of NPPES enumeration and PECOS enrollment data.
Detect and correct inaccurate and incomplete provider enumeration and enrollment data for new and established records.
Because the NPI is used by private and public health insurance programs, the lack of safeguards for NPPES data complicates program integrity efforts for all health care programs. CMS concurred with all three of recommendations while pointing out that severalenhancements have been made to PECOS that may decrease inaccuracies. In addition, CMS reported that it will improve accuracy through ongoing revalidation and provider education.
PECOS Enrolled Requirements
CMS temporarily delayed its plan to activate PECOS home health edits of claims for enrolled ordering and referring physicians as planned for May 1, 2013.
It is unclear how the OIG report will impact future activation plans. NAHC would like to be informed of home health agency and physician problems with PECOS by email to firstname.lastname@example.org we continue in our efforts to insist that CMS ensures that all PECOS related issues are resolved before edits are activated.