Michael F. Mangano /s/

Principal Deputy Inspector General

OIG Final Report: Inaccuracies in the Unique Physician Identification Number Registry:

Incorrect Addresses for Mental Health Service Providers, OEI-03-99-00131

Thomas Scully

Administrator

Centers for Medicare & Medicaid Services

SUMMARY 
The purpose of this memorandum is to present the Centers for Medicare & Medicaid Services 
(CMS) with information regarding the inaccuracy of provider data contained in the Unique 
Physician/Practitioner Identification Number (UPIN) Registry. We identified inaccurate 
addresses in the UPIN Registry for 28 percent of the providers in our sample during the course 
of an inspection assessing the appropriateness of Medicare Part B payments for outpatient 
mental health services. Even the Medicare carriers did not have correct addresses for all of 
these providers. We estimate that Medicare paid about $35 million ( $17 million) in 1998 for 
outpatient mental health services billed by providers with inaccurate mailing addresses. 
We recommend that CMS take steps to validate and update UPIN Registry data. 
BACKGROUND 
Unique Provider Identification Number Registry. The Consolidated Omnibus Budget 
Reconciliation Act of 1985 required CMS to establish a unique identifier for all physicians who 
provide services to Medicare beneficiaries. Since that time, CMS has assigned Unique 
Physician Identification Numbers (UPINs) to physicians who bill or perform services for 
Medicare payment, and established a database of physician enrollment information known as 
the UPIN Registry. In 1994, the Registry was expanded to include non-physician practitioners 
and group practices. The CMS contracts with a single carrier to maintain the Registry of 
providers who bill Medicare Part B. 
To obtain a UPIN, each health care practitioner or group practice must submit an application for 
enrollment in the Medicare program to the appropriate carrier. Currently, CMS has 
standardized provider enrollment and update forms for all carriers. As part of the enrollment 
process, practitioners must provide carriers with information such as full name; State in which 
the applicant is licensed or practicing; license, registration, or certification number; tax 
identification number; and mailing address for Medicare-related correspondence. Providers 
often furnish or bill for services from several locations in different carrier jurisdictions. 
Therefore, applicants must also provide an address for each practice setting where services are 
rendered, as well as a pay to address for each practice setting.  Page 2 - Thomas Scully 
Carriers validate the information contained in the enrollment application and assign a Provider 
Identification Number (PIN) for each of the applicants practice settings. The carrier then 
submits this information to the UPIN Registry. Additional data entry checks are performed by 
the Registry contractor and a UPIN is assigned to the practitioner. While practitioners may have 
more than one PIN (indicating more than one practice setting), they have only one UPIN. The 
Registry maintains data on each PIN under a providers UPIN. 
Once the Registry assigns a UPIN, the carrier is responsible for maintaining provider enrollment 
data and promptly notifying the UPIN Registry of changes, additions, or deletions reported by 
providers. According to the Medicare Carriers Manual, provider information in the Registry 
must be identical to provider information in carrier files, including all mailing, practice setting, 
and pay to addresses. Also, carriers must deactivate practice settings that have no Medicare 
claims activity for 12 consecutive months. 
Implementation Plan for the National Provider Identifier.  For purposes of administrative 
simplification, the Health Insurance Portability and Accountability Act of 1996 mandated the 
adoption of a standard, unique health identifier for each individual, employer, health plan, and 
health care provider for use in the health care system.1  These identifiers, known as National 
Provider Identifiers (NPIs), will be issued by the National Provider System. According to CMS, 
Medicare provider enrollment information contained in the UPIN Registry will be loaded into 
the National Provider System and NPIs will be assigned automatically to Medicare providers.2 
The NPIs would then replace UPINs in the Medicare program. 
Unique Provider Number Issues Previously Identified by the OIG.  Over the past 10 years, 
the Office of Inspector General (OIG) has issued several reports identifying problems with the 
completeness and accuracy of provider enrollment information in carriers files and the UPIN 
Registry. Between 1991 and 1992, the OIG found that some carriers did not require physicians 
to provide billing addresses on applications for enrollment. The OIG also found that many 
carriers were not updating provider files systematically, but were updating files only in response 
to returned mail or changes submitted by the provider. A 1999 OIG report estimated that 39 
percent of Provider Identification Numbers were still listed as active in the UPIN Registry 
despite the fact that those practice settings had no claims activity for 12 consecutive months. In 
addition, data collection experiences during two 1999 OIG inspections on provider readiness for 
the year 2000 raised questions about the accuracy of address data contained in the UPIN 
Registry. In the first study, 14 percent of physician surveys were returned as undeliverable, 
while 17 percent of physician surveys were returned due to inaccurate addresses during the 
second study. A listing of these report titles and numbers is presented in Attachment 1. 
1 Health Insurance Portability and Accountability Act of 1996, sec. 262, 1173(b) (1996). 
2 Centers for Medicare & Medicaid Services, formerly known as the Health Care Financing Administration, National Provider 
Identifier Frequently Asked Questions, 24 February 1999, <http://www.hcfa.gov/stats/npi/faq3-99.htm> (13 March 2001).  Page 3 - Thomas Scully 
METHODOLOGY 
We selected a sample of 1998 claims as part of a recent inspection to assess the appropriateness 
of Medicare Part B payments for mental health services provided in practitioners offices, 
community mental health centers, beneficiaries homes, and custodial care facilities. We 
collected mental health records from Medicare providers in support of sample services and 
forwarded these records to an independent contractor for medical review. 
Sample Selection. The stratified random sample of 650 claims was selected from a 1 percent 
file of paid 1998 Part B claims for nine mental health service codes provided in four outpatient 
places of service. This 1 percent file was created from CMS 1998 National Claims History file, 
which was 98 percent complete at the time of sample selection. After eliminating 8 claims for 
providers under review by the Office of Investigations, our working sample consisted of 
642 claims representing 571 individual providers. 
Sample Claims and UPIN Registry.  We accessed a CMS data file extracted from the UPIN 
Registry to obtain a full name and mailing address for each provider who billed for sample 
mental health services. A provider may have more than one practice setting. Therefore, in 
order to identify the most current address for each provider, we sorted Registry data and selected 
the most recently changed or added practice setting for each UPIN. We then matched sample 
claims to these practice settings using the UPIN and PIN. We obtained mailing addresses for 
561 of the 571 providers in the study sample using the UPIN Registry database. We contacted 
Medicare carriers to obtain mailing addresses for the remaining 10 providers, as we were unable 
to match sample claims to address data in the UPIN Registry. 
Documentation Request.  Using these addresses, we mailed written requests for beneficiaries 
medical records to the 571 providers of sample mental health services. Documentation requests 
were sent via Federal Express, except those for providers with post office box addresses. When 
mailings were returned to us as undeliverable, we took steps to find alternative provider 
addresses. For the first 23 returned mailings, we accessed Internet sites including the American 
Medical Associations Physician Select and WebMD to locate alternative provider addresses. 
However, when the volume of returns continued to grow, we contacted individual carriers to 
obtain alternative addresses for an additional 136 providers. We collected medical records from 
Medicare providers from February 2000 to June 2000. 
FINDINGS 
Addresses listed in the UPIN Registry database were inaccurate for 28 percent of 
providers 
Documentation requests mailed to 159 of 561 providers for whom we obtained mailing 
addresses from the UPIN Registry were returned as undeliverable due to inaccurate addresses. 
Examples of inaccurate addresses included street addresses without company names or suite 
numbers, and cases where providers had moved from or were unknown to persons at the mailing  Page 4 - Thomas Scully 
address. Inaccurate provider addresses were not limited to a small number of Medicare carriers. 
In fact, claims for providers with inaccurate addresses were billed to and paid by 37 of 62 
separate carrier numbers. Four of these carriers accounted for 36 percent of the 159 providers 
with inaccurate addresses. 
Carriers did not always have accurate addresses for these providers 
We contacted Medicare carriers to obtain alternative addresses for 136 providers whose initial 
mailings were returned as undeliverable. For 23 providers, carriers were not able to provide 
alternative addresses because they had the same inaccurate addresses on file that we used for 
mailing our initial documentation requests. Carriers were able to furnish alternative addresses 
for 113 providers. We sent documentation requests to all new provider addresses. However, 
mailings to 18 of the 113 alternative provider addresses supplied by Medicare carriers were 
returned as undeliverable. 
During our data collection period, we never received medical records for 50 services in the 
mental health study sample due to inaccurate addresses for 41 providers. Based on this data, we 
estimate that Medicare paid about $35 million ( $17 million) in 1998 for outpatient mental 
health services billed by providers with inaccurate mailing addresses. 
RECOMMENDATION 
Along with previous OIG reports that identified problems with the completeness and accuracy 
of provider data contained in carriers files and the UPIN Registry, this memorandum provides 
additional evidence that Medicare practitioner enrollment information contained in the UPIN 
Registry is not entirely accurate. Therefore, we recommend that CMS take steps to validate and 
update UPIN Registry data. 
AGENCY COMMENTS 
The CMS concurred with our recommendation and stated that, since the OIG review was 
conducted, it has taken steps to validate and update UPIN Registry data. The CMS noted that it 
has worked with the Medicare contractors and an additional contractor to improve the accuracy 
of data in the UPIN Registry, and has reduced their returned-mail rate to 5 percent. The CMS 
listed a number of factors that it believes may account for the high volume of mail returns in 
our study. The CMS also noted that it has not yet determined whether provider data already 
housed in the UPIN Registry will be loaded into the new National Provider System, or whether 
all providers will be required to apply for a National Provider Identifier. The full text of CMS 
comments is presented in Attachment 2.  Page 5 - Thomas Scully 
OIG RESPONSE 
We support CMS current and future efforts to improve the accuracy and validity of provider 
data contained in the UPIN Registry. These efforts are important whether or not CMS decides 
to use UPIN Registry data to populate the National Provider System when it is implemented. 
We also believe that the methods we used to select provider addresses and conduct our data 
collection mailing were sound, and provided a firm basis for our finding that UPIN Registry 
addresses for 28 percent of sample providers were inaccurate. 
The CMS suggested that the provider addresses we selected from the UPIN Registry for our 
mailing may have been inactive addresses. In February 2000, we selected addresses for sample 
providers from a UPIN Registry file that contained only active practice setting addresses. This 
source file was current as of January 2000. We recently reviewed UPIN Registry files 
containing both active and inactive practice setting addresses current as of May 2001. Only 
3 percent (5 of 159) of the provider addresses we found to be inaccurate are currently listed as 
inactive practice setting addresses that appear to have been deactivated just prior to our data 
collection period. In addition, our review indicates that almost 70 percent (110 of 159) of the 
provider addresses we found to be inaccurate in the spring of 2000 are still listed as active 
practice setting addresses in the UPIN Registry. 
The CMS believes that another reason for the high volume of mail returns in our study may be 
that, unlike the post office, Federal Express does not forward mail. We believe that our use of 
an express mail service provided a more reliable gauge of the validity of provider addresses than 
the use of standard mail service. If our letters had been forwarded to sample providers by the 
post office, we would never have known that the addresses we selected from the UPIN Registry 
were inaccurate. 
The CMS also questioned our use of business addresses and group practice addresses to contact 
providers rather than billing addresses, suggesting that this may also have contributed to the 
high rate of mail returns. The UPIN Registry file from which we selected provider addresses 
contains practice location addresses for solo practitioners and members of group practices, but 
does not contain providers billing addresses. Providers see patients at these practice location 
addresses, and we believe that these should be addresses where providers can be contacted. 
The CMS also suggested that we may have incorrectly matched provider identification numbers 
to UPIN Registry address data due to the computer software used in the study. In the 
methodology section of this report, we describe the process by which we identified and matched 
provider addresses from the UPIN Registry to standard provider identification numbers on 
sample claims. We believe there were no incorrect matches due to computer software error. 
Attachments  Attachment 1 
OIG Reports Cited in Memorandum 
Carrier Assignment of Medicare Provider Numbers, OEI-06-89-00871 
Carrier Maintenance of Medicare Provider Numbers, OEI-06-89-00870 
Accuracy of Unique Physician Identification Number Data, OEI-07-98-00410 
Y2K Readiness of Medicare Providers, OEI-03-98-00250 
Y2K Readiness of Medicare Fee for Service Providers as of July 1999, OEI-03-98-00253  Attachment 2 
Centers for Medicare & Medicaid Services Comments  Attachment 2