Medicare Advantage plans failing to collect info on imaging referrers, opening door for fraud
Medicare Advantage plans are failing to collect unique identifiers for providers who order imaging and other services, opening the door to potential fraud, according to a report released Wednesday.
Health plans continue to overlook this important info, despite having the data systems to collect such information. The Centers for Medicare and Medicaid Services must take action to address this issue, including potentially rejecting records that do not identify referrers, the Office of the Inspector General urged.
“[Durable medical equipment, prosthetics, orthotics and supplies] and laboratory, imaging, and home health services have a history of being vulnerable to fraud,” Health and Human Services’ OIG wrote in its Aug. 26 report. “For these items and services that are at high risk for fraud, ordering providers should act as gatekeepers against inappropriate payments, as they determine whether these items and services are medically necessary and appropriate for the patients they treat. Having access to identifiers for these ordering providers is essential for effective oversight of these items and services…”
To reach its conclusions, the OIG analyzed 2018 Medicare Advantage encounter info from CMS’ data repository. Investigators also sent an online survey to 200 health plans, with 179 responding. They found that about 60% of records in 2018 failed to include national provider identifiers. At the individual level, about 58% of Medicare Advantage imaging records were missing the identifier, compared to 62% for lab records and 17% for home health. This problem occurred despite 98% of MA organizations in the sample reporting that they have the capability to capture and store such information, the OIG noted.
Roughly 58% of MA plans in the sample said suppliers or providers actually submit an ordering provider’s identifier on at least half of claims or encounters. That number climbed as high as 80% in imaging. And yet, many did not submit this information, as CMS does not require them to do so the same way it does in regular fee-for-service Medicare.
To remedy these issues, the OIG is recommending—as it has in the past—to require Medicare Advantage plans to submit ordering provider identifiers. Plus, it wants CMS to reject any records that include a national provider identifier that is not valid and active.
Read the whole report here.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.