Inaccuracies in Medicare and Medicaid Provider Data Highlighted

A May 2013 Office of Inspector General for the Department of Health and Human Services report* analyzed the Provider data files of Medicare and found a very high error rate.

To quote portions of the Executive Summary:

“Medicare provider data in NPPES (National Plan and Provider Enumeration System) and PECOS (Provider Enrollment, Chain and Ownership System) were often inaccurate. In NPPES, provider data were inaccurate in 48% of records…. in PECOS, provider data were inaccurate in 58% of records…Addresses, which are essential for contacting providers and identifying trends in fraud, waste, and abuse, were the source of most inaccuracies and inconsistencies. Finally, CMA did not verify most provider information in NPPES and PECOS….

Because of reliance by many healthcare professionals on NPPES or PECOS data, errors in those databases impact provider billing, referring and contacting information, leading to large inefficiencies in both time and money ….and may even impact the delivery of healthcare to patients. And even NPPES and PECOS are miles ahead, in terms of accuracy, of the numerous ‘advertiser-supported’ physician databases that populate the Web.

The only way to successfully approach Provider Database accuracy is for a consistent, systematic and periodic ‘out reaching’ to Providers for direct verification of information. Accuracy cannot be achieved by self-reporting, it is expensive and has to be aggressively pursued.

*“Improvements Needed to Ensure Provider Enumeration and Medicare Enrollment Data are Accurate, Complete and Consistent” OEI-07-09-00440. Daniel R. Levinson, Inspector General

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November 2017
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