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Medicare Advantage Organizations' Use of Ordering Provider Identifiers for Program Integrity Oversight

National Provider Identifiers (NPIs) for ordering providers are essential for safeguarding the program integrity of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), clinical laboratory services, imaging services, and home health services in Medicare. However, CMS does not require Medicare Advantage organizations (MAOs) to collect NPIs for ordering providers. In past work, the Office of Inspector General (OIG) found that—although nearly two-thirds of Medicare Advantage encounter data records that MAOs submitted to CMS for DMEPOS, clinical laboratory, imaging, and home health services reviewed did not include the NPI for the ordering provider—almost all MAOs have the ability to collect ordering provider NPIs, and that many MAOs do collect these data. OIG recommended that CMS require MAOs to submit ordering provider identifiers. This issue brief will determine the extent to which MAOs conduct oversight of DMEPOS, clinical laboratory services, imaging services, and home health services using ordering provider identifiers.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
September 2020 Centers for Medicare and Medicaid Services Medicare Advantage Organizations' Use of Ordering Provider Identifiers for Program Integrity Oversight Office of Evaluation and Inspections OEI-03-19-00432 2021