Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

NPPES and PECOS: Inaccuracies and Inconsistences the OIG Found

A recent study conducted by the Office of Inspector General revealed that about half of all records in the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain and Ownership System (PECOS) are inaccurate, and 97 percent of the records were inconsistent between the two data repositories.

The NPPES  collects identifying information on health care providers and assigns a unique national provider identifier (NPI) in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which mandated the standard unique identifier for health care professionals. PECOS is a centralized national data repository established by the Centers for Medicare and Medicaid Services (CMS) for Medicare enrollment information utilized by Medicare Administrative Contractors throughout the country.

Medical providers must register through NPPES first to get an NPI number before they can enroll in Medicare through PECOS. While online registration allows providers to submit data directly to the repositories, paper applications also are accepted for both systems and are then entered by contractors so that the electronic databases contain all records (records for providers who enrolled in Medicare prior to 2003 may not be available in PECOS if the provider has made not subsequent updates).

Currently, no federal law requires that information in the two data systems be consistent. However, since both systems contain similar information and both systems are used to contact providers and to help combat fraud, waste, and abuse, inconsistencies between the two hinder federal programs.

The most common errors in each database, and the most common inconsistencies between the two databases, comprise provider contact information. In NPPES, 34.1 percent of records had an inaccurate mailing address and 33.3 percent of records had an inaccurate practice address. According to NPPES guidelines, changes in required data, such as mailing and practice address, must be communicated by providers within 30 days of the change.

In PECOS, 46.8 percent of primary mailing addresses were inaccurate, with primary practice address and secondary mailing address wrong 8.7 percent and 7.9 percent, respectively. Providers are required to report changes in required information to PECOS within 90 calendar days of change.

Between the two databases, practice location addresses were mismatched 88.6 percent of the time, with telephone number and mailing address mismatched 59 percent and 50.7 percent, respectively. Interestingly, the only indicator for verifying and matching addresses in the study was ZIP code to avoid minor differences that might skew results.

However, according to CIPROMS Credentialing Specialists, Vicky Stafford and Laura McDonald, even those kinds of minor differences between the records can hinder Medicare enrollment or the ongoing Medicare revalidation initiated by CMS in 2010. That effort, which requires all Medicare suppliers and providers enrolled in Medicare prior to March 25, 2011, to revalidate their enrollment, was intended to help rectify the inaccurate and inconsistent data known to exist in these national databases. However, the inaccurate data currently on record is making the process difficult for providers with letters being sent to wrong or outdated addresses, and revalidation applications being delayed or denied because they do not match incorrect or inaccurate data on file.

After finding the widespread inaccuracies and inconsistencies between NPPES and PECOS, the OIG has made the following recommendations to CMS:

  1. Require MACs to verify all provider enrollment data in PECOS, including credentials, mailing addresses, practice locations, telephone numbers, legitimacy of business, and adverse legal action.
  2. Require more verification of provider data in NPPES, including the enablement of NPPES contractor staff to immediately deactivate or suspend the NPIs of providers presumed to be deceased.
  3. Detect and correct inaccurate and incomplete provider enumeration and enrollment data for new and existing records, by revalidating more frequently, implementing automated edits, reducing or eliminating paper applications for enumeration and enrollment, and  incentivizing accurate and current data for providers.

CIPROMS also recommends that providers confirm their enumeration and enrollment data, and make changes by logging into NPPES and/or PECOS to check and correct inaccurate or incomplete data, or submitting paper requests for changes to be made via the NPI Application/Update Form or the CMS 855 form, especially if they are still waiting to be revalidated. Keeping enumeration and enrollment data up to date will allow the revalidation process to go much more smoothly than it otherwise would.

For more information, please review the OIG May 2013 report, Improvements Needed to Ensure Provider Enumeration and Medicare Enrollment Data Are Accurate, Complete, and Consistent.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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