As discussed in a previous post, we discussed provider directories and the gross accuracy issues that exist in them. Moreover, it was note that government has significantly increased the pressure on Medicare Advantage plans to better ensure accuracy by threatening plans with gross inaccuracies with bans on enrolling new members, marketing their plans, and fines up twenty-five thousand dollars per beneficiary per day. While the burden of auditing and paying for fines largely remains with the health plans, much of the actual day-to-day burden with updating and entering accurate data into the directories of the various health plans lives with the provider community. The average provider – according to some statistics – is in-network with twenty plans and, therefore, must keep at least twenty directories accurate. Especially for small practices with limited administrative personnel, this can be a significant burden that takes time away from more productive, patient-centric activities.

            There are two significant CMS directories that must be updated regularly by providers: the national NPI directory or NPPES. This is a web directory – that is also an API and data extract – that can be used by various parties to find NPI numbers and other information about providers. It is important to keep this site accurate, and it can be updated rather easily. One must first go to the NPPES website and sign-up for an account. To sign-up for an account, one must have the following information: the provider’s first and last name, Social Security Number, EIN, NPI number, and date of birth. With that information, the remaining information on the site can be updated either directly online or with a form that can be downloaded, printed, and sent in.

            Physician Compare is another public directory CMS hosts that must be updated on a regular basis. The information on this site is used by the public to determine – in addition to other items – if a provider participates in Medicare, training, hospital affiliations, and whether or not a specific provider has satisfactorily participated in CMS quality programs. There is also information on hospitals as well.

While Physician Compare is itself a provider directory, it depends on another CMS directory for its information. The directory that it depends on is called PECOS or Provider Enrollment, Chain, and Ownership System. PECOS or its paper alternative are used by providers to enroll as Medicare-accepting providers. Enrolling in PECOS requires a significant amount of information including – but not limited to – educational information, professional licensure information (license number, renewal date, issuing state), legal name, date of birth, Social Security Number, DEA Number, practicing location information, and an NPI (and a group NPI if part of an organization that is not a sole proprietorships). PECOS – as with NPEES and other provider directories – must be kept up-to-date by physicians.

A subset of PECOS data and other Medicare reporting data (specifically the results of quality programs such as GPRO – Group Practice Reporting Option – and MIPS, the replacement for Meaningful Use) are used by CMS to populate the Physician Compare website; thus, accurate quality program participation data and accurate PECOS data are important to ensure that a provider is properly represented in PECOS. PECOS and NPPES are just two of the myriad of physician directories that exist. These two – as they have public facing components that are available to the general public, not only plan participants – are extremely important for providers. Moreover, especially with the NPPES, third-parties may access the data and use it for a variety of purposes. While updating these sites can be a hassle – especially for physician practices with staffing shortages – they are two the easier ones to update. For additional, information one each site, one can begin by searching on CMS’s website.

Categories: Healthcare

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