Medicare's doctor records riddled with errors

Incorrect enrollment information on physicians participating in Medicare can lead to doctors losing billing privileges and inaccurate information being posted on the Physician Compare website.

By Charles Fiegl amednews staff — Posted June 17, 2013

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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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How to check Medicare enrollment online

Physicians can review, update and correct their Medicare enrollment records by checking the online Provider Enrollment, Chain and Ownership System.

  • Go to the PECOS website and enter login information (link).
  • Click the “My Enrollments” button under the Manage Medicare and Account Information section.
  • Select “View Enrollments” under the Existing Associates section. Each enrollment record shows the physician's specialty type, state and current status.

Source: “Instructions for Viewing Individual Practitioner Status and Specialty Type in PECOS,” Centers for Medicare & Medicaid Services (link)

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What Medicare's enrollment systems get wrong

Federal auditors criticized Medicare officials for inaccuracies in enrollment systems meant to prevent fraud in the program. Errors related to addresses were the main reason for mistakes in the Provider Enrollment, Chain and Ownership System and the National Plan and Provider Enumeration System, but officials found inconsistencies in other fields used to identify and verify physicians.

Variable Error rate
Mailing address (primary) 34.1% 46.8%
Practice address 33.3% 8.7%
License (primary) 4.0% 7.1%
Credentials 1.6% 4.8%
Date of birth 1.6% 0.8%
Last name 0% 2.4%
Any variable 48.4% 57.9%

Source: “Improvements Needed to Ensure Provider Enumeration and Medicare Enrollment Data Are Accurate, Complete and Consistent,” Health and Human Services Office of Inspector General, May (link)

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External links

National Plan and Provider Enumeration System (NPPES) (link)

Medicare Provider Enrollment, Chain, and Ownership System (PECOS) (link)

“Improvements Needed to Ensure Provider Enumeration and Medicare Enrollment Data are Accurate, Complete and Consistent,” Health and Human Services Office of Inspector General, May (link)

“Instructions for Viewing Individual Practitioner Status and Specialty Type in PECOS,” Centers for Medicare & Medicaid Services (link)

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