The OIG issued a report titled “Improvements Needed to Ensure Provider Enumeration and Medicare Enrollment Data Are Accurate, Complete, and Consistent,” in which it details multiple failings in the reliability of the data contained in the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain and Ownership System (PECOS).  The OIG summarized its finding as follows: “Medicare provider data in NPPES and PECOS were often inaccurate and occasionally incomplete, and were generally inconsistent between the two databases.”  The OIG study revealed that provider data were inaccurate in a whopping “58 percent of records” in PECOS and that “provider data were inconsistent between NPPES and PECOS for 97 percent of records.”  According to the OIG, “[a]ddresses, which are essential for contacting providers and identifying trends in fraud, waste, and abuse, were the source of most inaccuracies and inconsistencies.”

Given these findings, the OIG recommended that CMS “require Medicare Administrative Contractors to implement program integrity safeguards for Medicare provider enrollment as established in the Program Integrity Manual.”  In addition, the OIG recommend that CMS “require more verification of NPPES enumeration and PECOS enrollment data” and “detect and correct inaccurate and incomplete provider enumeration and enrollment data for new and established records.”  CMS concurred with all three of the OIG’s recommendations.  As MACs react to exhortations from CMS to do a better job in reviewing 855’s, providers may experience greater delays in going through the enrollment process.

Reporter, Daniel J. Hettich, Washington, D.C., +1 202 626 9128, dhettich@kslaw.com.