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Investigation: Medicare provider data ‘inaccurate, incomplete and inconsistent’

By   /   June 6, 2013  /   2 Comments

By Carten Cordell │ Watchdog.org, Virginia Bureau

ALEXANDRIA — On the eve of an historic expansion of the federal government’s role in American healthcare, a new report finds Medicare databases riddled with errors and wide open to fraud.

An inspector general’s report released last week found that the data systems used to catalog the records of Medicare providers were riddled with inaccurate or incomplete information.  The report found 97 percent of files studied revealed internal inconsistencies.

The report, released by the Department of Health and Human Services’ inspector general, focused on two Medicare databases that manage important provider information, the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain and Ownership System (PECOS).

An inspector general's report has found Medicare's databases for processing medical providers "inaccurate", opening the door for potential waste, fraud and abuse.

An inspector general’s report has found Medicare’s databases for processing medical providers “inaccurate”, opening the door for potential waste, fraud and abuse.

The systems contain the information and identifiers of healthcare providers enrolled in Medicare and assist the government healthcare system in processing payments to those providers.

The report found data in both systems was “often inaccurate and occasionally incomplete, and were generally inconsistent between the two databases.”

Nearly half—48 percent—of the files containing identifiers assigned to providers by the Centers for Medicare &Medicaid Services were inaccurate.

PECOS, which is used to process provider information, had inaccuracies in 58 percent of its files. When provider information from both databases was compared, 97 percent of the files had conflicting information, including the addresses of providers that were billing Medicare.

The report also found that CMS did not verify most of the information in either database, raising the possibility that fraudulent information had been used to scam the system.

But the inspector general’s report found that while CMS had processes in place to verify provider data, “the manner in which CMS implemented these processes impeded efforts to ensure that the databases contained accurate information.”

Faced with surging provider applications to fill the increased role of Medicare, CMS allowed for the suspension of other verification processes that may have caught inaccurate data.

“The suspension of provider enrollment verification activities at a time of increased application volume could have compromised the accuracy and completeness of PECOS data, increasing the vulnerability of the Medicare program to fraud and abuse,” the report said.

The report, which was released on May 29, comes just as the White House touted how the Affordable Care Act’s expansion of the government healthcare giant has ensured its solvency until at least 2026.

A press release from the Obama administration on May 31 cited the Medicare Trustees’ annual report, which said the Hospital Insurance Trust Fund’s long run actuarial deficit had been cut by more than 70 percent since the ACA became law, helping to project Medicare solvency for two years longer than the 2012 report.

The White House also highlighted new care models that incentivize providers to manage costs for Medicare patients.

“And our data and health information technology initiatives are driving a wave of innovation as entrepreneurs and innovators develop and deploy new digital tools to help clinicians deliver better care across the country,” the press release said.

The report also noted that CMS oversight allowed for ineffective safeguards in the verification process and suspended others to expedite the processing of provider information.

The inspector general’s office recommended stronger oversight and safeguards after noting that three out of four providers identified inaccurate data in either system.

CMS had not commented by publication.

Email Carten Cordell at carten@watchdogvirginia.org


  • joan

    I remember reporting an error in my mother’s medicare bill, that a Dr. that I did not know had billed visits to her in nursing care, I did not get a satisfactory response from Medicare, so I called the Dr. who was supposed to be the attending physician and reported it to him. He had the assistant fired. Never got back the payment from him as far as I know, and this was years ago. this has always been a place for fraud. Then the doctors that do treat people properly do not get enough reimbursement.

  • Kevin

    Seems no one ever does their job in the Govt run offices! I reported several physicians of fraud from first hand accounts and absolutely NOTHING was done! In the long run the seniors end up paying for this lazy incompetence one way or another, then Govt wants to scream Medicare is going broke (of course we know Obama stole from it) so OBAMA needs to stop giving billions to countries who hate us and want to kill us and fix our broken systems!

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