The Department of Health and Human Services (HHS) OFFICE of INSPECTOR GENERAL (OIG) has issued a report, “Improvements Needed to Ensure Provider Enumeration and Medicare Enrollment Data Are Accurate, Complete, and Consistent,” which found that data contained in the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain and Ownership System (PECOS) was often inaccurate, incomplete, and inconsistent.
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 the following:
- In NPPES, 48 percent of records contained inaccurate data; almost all required data were complete. The most common inaccuracies were reported in mailing and practice addresses.
- In PECOS, 58 percent of records contained inaccurate data and almost 4 percent were incomplete. The most common inaccuracies were reported in mailing and practice addresses.
- Provider data were inconsistent between NPPES and PECOS for 97 percent of records. More than half of the records were inconsistent between the databases for required provider contact information, such as practice location address (89 percent) and mailing address (51 percent). The practitioner license number was inconsistent between NPPES and PECOS for 42 percent of records, but it is a conditionally required variable for both databases.
- CMS did not verify most provider information in NPPES or PECOS, even though it had processes in place to do so. CMs instructed Medicare Administrative Contractors (MACs) to verify only one provider variable in NPPES (Social Security number) and only four provider variables in PECOS (Social Security number, National Provider Identifier (NPI), state licensure, and exclusion data).
In response to these findings, the OIG recommended that CMS should require MACs to implement program integrity safeguards for Medicare provider enrollment as established in the Program Integrity Manual, CMS should require more verification of NPPES enumeration and PECOS enrollment data, and CMS should detect and correct inaccurate and incomplete provider enumeration and enrollment data for new and established records. CMS concurred with all three recommendations.