Vulnerabilities in CMS’ preclusion process contributed to Medicare Advantage and Part D plans making $72 million in payments for services linked to revoked providers from 2022 through 2024, the HHS Office of Inspector General found.
Revocation ends a provider’s enrollment in traditional Medicare Parts A and B. The preclusion list bars payment to listed providers under MA and Part D. OIG found 1,017 revoked national provider identifiers, associated with excluded providers or people with certain felony convictions, that were not on the preclusion list as of Dec. 31, 2023. The $72 million in payments was tied to 249 of these 1,017 NPIs. OIG reviewed payments tied to those NPIs through 2024.
According to the report, there were timing issues and errors with CMS updating the preclusion list. The NPIs of some organizations whose owners had been excluded or convicted of certain felonies were also left off the preclusion list. CMS said current rules limit its ability to preclude organizations based on an owner’s conduct.
The report added that, under current regulations, pharmacies that do not prescribe Part D drugs and only fill prescriptions do not face preclusion. Twelve of the revoked NPIs were pharmacies. These pharmacies filled Part D prescriptions that led to plan payments of $42 million. The pharmacy payments were part of $51 million in Part D payments, and Part C payments accounted for $21 million.
During the audit, CMS reviewed the 1,017 NPIs, ultimately precluding 537. The agency said it could not preclude the 172 revoked NPIs registered to organizations, and 232 did not need preclusion. After considering OIG’s analysis, CMS plans to preclude the remaining 76 revoked NPIs.
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