Inaccurate Medicare databases ripe for fraud

Provider information stored on a pair of Medicare databases was determined to be both incomplete and inaccurate, according to a new report by the U.S. Department of Health & Human Services Office of Inspector General. The databases--the National Plan and Provider Enumeration System (NPPES) and the Provider Enrollment, Chain and Ownership System (PECOS)--are used to determine provider identities, which helps to prevent the occurrence of fraud.

Provider data stored in NPPES--which includes unique National Provider Identifiers--was found to be inaccurate 48 percent of the time, and incomplete for conditionally required variables nine percent of the time. Similar information stored in PECOS, meanwhile, was inaccurate 58 percent of the time, and incomplete in close to four percent of records.

Information shared between the two databases were found to be inconsistent with one another in a whopping 97 percent of records, with provider addresses providing the most inaccuracies.

"Inaccurate, incomplete and inconsistent provider data, coupled with insufficient oversight place the integrity of the Medicare program at risk and present vulnerabilities in all healthcare programs," OIG said. "[T]he results of our analyses show that NPPES and PECOS data are not reliable independently or even when combined.

Aside from calling for corrections to the inaccurate information, OIG recommended that the Centers for Medicare & Medicaid Services require increased "verification of NPPES enumeration and PECOS enrollment data."

Earlier this month, the U.S. charged 89 people in eight cities with healthcare fraud that involved $223 million in fraudulent claims. It was the government's sixth national crackdown on healthcare fraud since 2010 although, according to Attorney General Eric Holder, budget cuts due to sequestration could limit similar efforts in the future.

To learn more:
- here's the OIG report (.pdf)