OIG: Medicare Advantage encounter data rarely complete

CMS' encounter data continues to lack identifiers for ordering providers, which are used to identify potential fraud and abuse, according to a report from HHS' Office of Inspector General. 

To come to this conclusion, OIG extracted and analyzed 2018 Medicare Advantage encounter data from CMS. OIG also surveyed a stratified random sample of 200 Medicare Advantage Organizations, receiving an answer from 179 of them.

What OIG found is CMS' Medicare Advantage encounter data rarely has complete national provider identifiers for providers that order durable medical equipment, prosthetics, orthotics, and supplies, as well as clinical laboratory, imaging and home health services. The identifiers help OIG find inappropriate billing and ordering patterns in fraud and abuse investigations. 

Despite the lack of data, OIG found most Medicare Advantage organizations can receive and store national provider identifiers when providers submit claims or encounter records.

OIG recommended that CMS require Medicare Advantage organizations to submit the ordering provider identifier on encounter records and reject encounter records where the identifier is missing or inaccurate. 

Read the full report here

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