U.S. Department of Health and Human Services 
Office of Inspector General 
Issue Brief 
April 2021, OEI-03-19-00432 
 
Medicare Advantage Organizations Are Missing Opportunities To 
Use Ordering Provider Identifiers To Protect Program Integrity 
This issue brief summarizes results from our evaluation of Medicare 
Key Results 
Advantage organizations (MAOs) use of National Provider 
Identifiers (NPIs) for physicians and nonphysician practitioners who  Although many MAOs use 
order and/or refer high-risk servicesi.e., durable medical  identifiers for ordering providers 
equipment, prosthetics, orthotics, and supplies (DMEPOS); clinical  to conduct oversight activities, 
other MAOs are missing 
laboratory services; imaging services; and home health servicesfor 
opportunities to safeguard 
Medicare Advantage (MA) enrollees.  (In this issue brief, we refer to 
Medicare Advantage program 
these providers as ordering providers.)  
integrity. 
Why OIG Did This Review  
NPIs for ordering providers are essential for safeguarding the program integrity of high-risk services in 
Medicare.  For these services, NPIs are critical for identifying patterns of inappropriate billing and 
ordering among providers and investigating fraud and abuse.  Both the Centers for Medicare & 
Medicaid Services (CMS) and the Office of Inspector General (OIG) rely on ordering provider NPIs 
(hereafter ordering NPIs) to conduct oversight and pursue fraud investigations.  However, prior OIG 
work found that these NPIs were largely absent from CMSs MA encounter data, despite evidence that 
many MAOs canand doalready collect this information.  (Encounter data are detailed information 
submitted by MAOs to CMS regarding each service provided to MA beneficiaries.)  As a result, OIG 
recommended that CMS establish and enforce requirements for MAOs to submit ordering NPIs for 
high-risk services.  Findings from this issue brief may be useful as CMS considers requiring MAOs to 
collect and use ordering NPIs for MAOs program integrity oversight activities.  
How OIG Did This Review 
To determine the extent to which MAOs conducted program integrity oversight activities by using 
ordering NPIs submitted by providers and/or suppliers of high-risk services, we administered an online 
survey to a stratified random sample of 200 MAOs from February to March 2020.  We received 
responses from 179 MAOs.  This is the second OIG issue brief that analyzes data from this survey; the 
first was released in August 2020 and focused on the extent to which MAOs collected ordering NPIs 
and submitted these identifiers to CMSs MA Encounter Data System. 
What OIG Found 
Almost half of the MAOs that lack ordering NPIs on at least some MA encounter records raised 
concerns that this hinders their data analysis for program integrity.  Among MAOs that collect any 
ordering NPIs, most use these NPIs to conduct oversight activitiessuch as analyses that detect 
potential fraud schemesbut one in five of these MAOs does not perform program integrity oversight 
using ordering NPIs, despite having the data to do so.  Furthermore, when MAOs collect ordering NPIs 
on MA encounter records, most do not validate these NPIs against CMSs NPI registry.  These findings 
indicate that there are unrealized opportunities for MAOs to use ordering NPIs to protect the MA 
program against fraud and abuse.  What OIG Recommends 
This evaluation adds support for OIGs existing recommendations that CMS: 
  require MAOs to submit the ordering NPIs on encounter records for DMEPOS and for clinical 
laboratory, imaging, and home health services; and  
  establish and implement reject edits that (1) reject encounter records in which the ordering 
NPIs is not present when required and (2) reject encounter records that contain an ordering 
NPIs that is not a valid and active NPI in the CMSs NPI registry. 
On the basis of this evaluation, we are making a new recommendation that CMS should encourage 
MAOs to perform program integrity oversight using ordering NPIs.  CMS neither concurred nor 
nonconcurred with this recommendation and stated that it would consider whether additional 
education is needed for MAOs regarding the role that ordering NPIs can play in program integrity 
oversight.   
BACKGROUND
 
 
DMEPOS and clinical laboratory, imaging, and home health 
services are vulnerable to fraud 
DMEPOS and clinical laboratory, imaging, and home health services have a history of 
being vulnerable to fraud.  (In this issue brief, we refer collectively to DMEPOS and these 
services as high-risk services.)  In 2019, law enforcement identified DMEPOS suppliers 
that allegedly paid kickbacks to providers who ordered medically unnecessary DMEPOS 
for Medicare beneficiaries, potentially defrauding taxpayers out of $900 million.1  In 
addition, a separate scheme involved a laboratory that allegedly paid kickbacks to 
ordering providers and fraudulently billed Medicare $1.7 billion for genetic tests that 
were not medically necessary.2  For these high-risk services, ordering providers should 
act as gatekeepers against inappropriate payments, as they determine whether these 
services are medically necessary and appropriate for the patients they treat.  Having 
access to identifiers for these ordering providers is essential for effective oversight of 
these services, and analysis of ordering NPIs is critical for identifying inappropriate billing 
and ordering patterns among providers.  Both CMS and OIG rely on these identifiers to 
conduct oversight and enforcement work.  
CMS requires MAOs to safeguard MA program integrity 
Under MA, also known as Medicare Part C, CMS contracts with private insurance 
companies, known as MAOs, to provide coverage of Medicare Part A and B services 
through private health plan options.  In 2020, 40 percent of Medicare beneficiaries 
25 million beneficiarieselected to enroll in the MA program rather than the Medicare 
fee-for-service program.3  In fiscal year 2020, MA program expenses were $314 billion of 
the total $780 billion in Medicare benefit payments.4 
CMS requires MAOs to implement effective compliance programs that include measures 
to safeguard the MA program from fraud, waste, and abuse.5  To implement an effective 
compliance program, MAOs may perform data analysis to identify unusual patterns 
suggesting potential errors and/or potential fraud and abuse.6  CMS recommends that 
this data analysis should, in part, establish baseline data to enable the MAO to recognize 
unusual trends and provider referral patterns.  In addition, as part of MAOs monitoring 
of providers in their network, CMS suggests that MAOs review Prescribing and Referral 
Patterns by Physician Reports, which identify the numbers of referrals from particular 
providers.7  
CMS also requires MAOs to submit encounter records that contain detailed information 
regarding services provided to MA beneficiaries.  However, CMS does not currently 
require MAOs to submit the ordering NPI on encounter records for any high-risk 
services.  In January 2020, CMS issued a memo acknowledging that a lack of ordering 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432        Background | 1   
provider information in encounter records for DMEPOS and clinical laboratory, imaging, 
and home health services hinders potential program integrity efforts.8  As such, CMS 
encouraged MAOs to monitor, evaluate, and take measures to ensure appropriate 
submission of ordering provider identifiers for MA encounter records. 
Prior OIG work found that CMSs encounter data lacked 
ordering NPIs that MAOs have the ability to collect 
This issue brief builds on prior OIG work related to ordering NPIs in the MA program.  In 
2018, OIG found that ordering NPIs were absent from 63 percent of MA encounter 
records for high-risk services from the first quarter of 2014.9  In 2020, OIG found that 
NPIs for ordering providers continued to be absent from 60 percent of MA encounter 
records for high-risk services from 2018, even though (1) almost all MAOs reported that 
their data systems can receive and store this information, and (2) the majority of MAOs 
reported that they collect ordering NPIs on at least half of their MA encounter records 
for DMEPOS, imaging services, and laboratory services.10   
As a result of these findings, OIG has recommended that CMS require MAOs to submit 
the ordering NPI on encounter records for high-risk services.  In addition, OIG has 
recommended that CMS establish and implement what are known as reject edits for 
certain types of encounter records, such as those related to high-risk services.  Such edits 
would (1) reject records in which the NPI and/or name for the ordering provider is not 
present; and (2) reject records that contain an ordering NPI that is not valid and active in 
CMSs NPI registrythe National Plan and Provider Enumeration System (NPPES).11   
CMS concurred with our first recommendation and is exploring implementation of a 
requirement for MAOs to submit the ordering NPI on encounter records for high-risk 
services.   
CMS did not concur with our second recommendation and stated that it would be 
premature to establish and implement reject edits until it had explored the requirement 
for MAOs to submit the ordering NPI on encounter records for high-risk services. 
   
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432        Background | 2   
 
FINDINGS 
 
The lack of ordering NPIs on some MA encounter records 
hinders program integrity oversight by MAOs 
Almost half of the MAOs that lack ordering NPIs on some MA encounter records stated 
that this hinders their data analysis for program integrity.  Many of the MAOs that we 
If the ordering 
surveyed (81 of 179) lacked NPIs on at least some of their encounter records.12  Of these 
provider NPI is not 
MAOs, almost half (36 of 81) raised concerns that this lack of ordering NPIs hinders their 
present on the claim, 
performance of data analysis for program integrity oversight of high-risk services.  
analysis for Medicare 
Advantage  
Some MAOs indicated that their lack of ordering NPIs creates additional resource 
program integrity 
burdens and delays for safeguarding MA program integrity.  For example, one MAO 
 is more difficult and 
explained that without the ordering physician NPI, medical records must be requested 
less timely. 
from the provider to determine who ordered the services.  Another MAO explained, If 
 
ordering NPI is not present or available in the data, [our] Special Investigation Unit will 
-MAO respondent 
manually search for NPI numbers for data analysis.  
MAOs generally did not collectin place of NPIsother identifiers 
for ordering providers that could be used for program integrity 
oversight 
In the absence of NPIs, 
Exhibit 1: MAOs whose lack of ordering NPIs 
MAOs could use other 
hindered their program integrity oversight also 
identifying information 
lacked other ordering provider identifiers 
about ordering 
providerssuch as their 
names, their Employer 
Identification Numbers, or 
their medical license 
numbersto identify 
patterns of questionable 
billing.  However, among 
MAOs that reported that 
their lack of ordering NPIs 
hinders their program 
integrity efforts, most 
(27 of 36 MAOs) generally 
Source:  OIG analysis of MAO responses to 2020 OIG survey.  
did not collect other 
identifiers for any of the high-risk services, as shown in Exhibit 1.13 
 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432         Findings | 3   
Among MAOs that collect ordering NPIs, most but not all 
leverage this critical information to safeguard the MA program 
Seventy-nine percent of the MAOs that collect ordering NPIs use 
these NPIs to conduct program integrity oversight  
Of the MAOs that collected 
Exhibit 2: MAOs use ordering NPIs to 
ordering NPIs on any MA 
perform a variety of oversight activities 
encounter records, most (139 of 
175) stated that they use these 
NPIs to perform program integrity 
activities for at least 1 of the 
4 high-risk services.  For example, 
MAOs may use ordering NPIs to 
detect potential fraud schemes, 
identify providers who are 
excessively ordering certain services 
or billing for medically unnecessary 
services, or to validate the identity 
of new, noncontracted providers.  
Other examples of oversight 
activities performed by MAOs are 
shown in Exhibit 2.   
 
 
 Source:  OIG analysis of MAO responses to 2020 OIG survey.  
The remaining 21 percent do not use ordering NPIs to conduct 
program integrity oversight 
In the Medicare Managed Care Manual, CMS states that MAOs must perform effective 
monitoring to prevent and detect fraud, waste, and abuse, and that they may accomplish 
this using data analysis.  Specifically, CMS recommends that MAOs use data analysis to 
establish baseline data by which to recognizeamong other thingsunusual patterns of 
referrals.14  Despite this guidance, 21 percent of MAOs that collected ordering NPIs for 
any of the high-risk services (36 of 175) did not perform program integrity oversight that 
used these NPIs.  Ten of these 36 MAOs reported that providers submitted ordering NPIs 
on most of their MA encounter records for each of the high-risk servicesyet these 
10 MAOs still did not leverage the potential of these data for program integrity 
oversight.15  An additional 14 of these 36 MAOs reported that providers submitted 
ordering NPIs on most of their MA encounter records for at least 1 of these high-risk 
services, and yet these 14 MAOs did not regularly use these data to perform program 
integrity oversight for that service.16 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432         Findings | 4   
Most MAOs that collect ordering NPIs do not validate them 
against CMSs NPI registry 
Most MAOs do not verify that the ordering NPI is in CMSs NPI registry when they receive 
an MA encounter record for a high-risk service.  In general, to provide services to 
Medicare beneficiaries, a provider should have a valid and active NPI in CMSs NPI 
registry.  Among MAOs that collected at least some ordering NPIs for each of the four 
high-risk services, three-quarters did not verify for at least one service type that these 
NPIs were present in the NPI registry.17  Within each individual service type, more than 
70 percent of the MAOs that collected ordering NPIs did not verify that NPIs were present 
in the NPI registry, as shown in Exhibit 3.  
Exhibit 3: Most MAOs do not verify that the ordering NPI is present in 
CMSs NPI registry 
 
Source: OIG analysis of MAO responses to 2020 OIG survey. 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432         Findings | 5  CONCLUSION AND RECOMMENDATION 
CMS and OIG agree that ordering NPIs are critical for identifying patterns of questionable 
billing and pursuing fraud investigations for services that have a history of being 
vulnerable to fraud.  However, previous OIG work found that these NPIs have been largely 
absent from CMSs MA encounter data, despite evidence that many MAOs canand do 
already collect this information.  Therefore, OIG recommended that CMS establish and 
enforce requirements for MAOs to submit ordering NPIs for applicable services.   
In response to our previous work, CMS stated that it is exploring implementation of a 
requirement for MAOs to submit the ordering NPI on encounter records for high-risk 
services.  Findings from our recent survey of MAOs may be useful as CMS continues to 
explore implementing this requirement.  We found many MAOs acknowledge that the 
absence of ordering NPIs on even a small portion of encounter records can hinder their 
performance of data analysis for MA program integrity.  Despite this hindrance, the 
landscape is promising in how MAOs are leveraging the NPI data that they do have.  
However, more widespread use is needed.  While most MAOs are using their ordering 
NPIs to conduct program integrity oversight activitiessuch as analysis that detects 
potential fraud schemesa fifth of MAOs are missing this opportunity completely.  In 
addition, most MAOs do not verify that the ordering NPI is present in CMSs NPI registry 
when they receive this information on an MA encounter record.  This creates a 
vulnerability by increasing the risk that invalid, inactive, or fraudulent providers are 
ordering high-risk services.  
Taken together, our findings indicate that (1) many MAOs agree that increased collection 
of ordering NPIs has the potential to strengthen their oversight of high-risk services and 
(2)there are unrealized opportunities for MAOs to use their existing data on ordering
NPIs to safeguard the MA program against fraud and abuse.  Therefore, this evaluation
adds support to OIGs existing recommendations that CMS:
 require MAOs to submit the ordering NPI on encounter records for DMEPOS and
for clinical laboratory, imaging, and home health services and
 establish and implement reject edits that (1) reject encounter records in which the
ordering NPI is not present when required and (2) reject encounter records that
contain an ordering NPI that is not a valid and active NPI in the NPPES registry.
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432      Conclusion and Recommendation | 6   
We recommend that CMS:  
Encourage MAOs to perform program integrity oversight using 
ordering NPIs 
Federal regulations require MAOs to perform effective monitoring to prevent and detect 
fraud, waste, and abuse.18  We found that MAOs did not always perform program 
integrity oversight that used these NPIs.  Therefore, CMS should encourage MAOs to 
conduct oversight activities using ordering NPIs in order to safeguard the MA program 
from fraud and abuse.  Such efforts may include, but are not limited to: 
  issuing clear and specific guidance about using ordering NPIs to conduct 
oversight, such as performing data analyses to detect potential fraud;  
  developing a best practices toolkit that outlines effective methods for data 
analyses that use ordering NPIs and highlights the benefits and return on 
investment in performing these analyses; 
  assessing MAOs use of ordering NPIs to conduct oversight activities as part of 
Compliance Program Effectiveness audits or through other assessments; and/or 
  identifying MAOs that do not use ordering NPIs to conduct oversight and 
providing education and outreach to these MAOs.  To assist CMS in identifying 
these MAOs, OIG will send CMS a list of the 36 MAOs from our sample that 
collected ordering NPIs on MA encounter records for high-risk services but did 
not perform any program integrity oversight that used these NPIs.   
 
 
   
 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432      Conclusion and Recommendation | 7  AGENCY COMMENTS AND OIG RESPONSE 
CMS neither concurred nor nonconcurred with our recommendation to encourage 
MAOs to conduct oversight activities using ordering NPIs in order to safeguard the MA 
program from fraud and abuse.  Instead, CMS stated that it would consider whether 
additional education is needed for MAOs regarding the role that ordering NPIs can 
play in program integrity oversight.  In addition, CMS noted that it released a memo in 
January 2020 encouraging MAOs to monitor, evaluate, and take measures to ensure 
appropriate submission of ordering provider identifiers in encounter records.  We 
continue to recommend that CMS take additional steps, such as those we described in 
our recommendation, to promote MAOs use of NPIs for program integrity activities.  
We also ask that CMS include any plans to do so in its Final Management Decision. 
Appendix A provides the full text of CMSs comments. 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432   Agency Comments and OIG Response | 8  APPENDIX A:  Agency Comments
DATE:           February 24, 2021 
TO:  Suzanne Murrin 
Deputy Inspector General for Evaluation and Inspections 
FROM:  Elizabeth Richter 
Acting Administrator 
SUBJECT:  Office of Inspector General (OIG) Draft Report: Medicare Advantage 
Organizations Are Missing Opportunities to Use Ordering Provider Identifiers to 
Protect Program Integrity (OEI-03-19-00432) 
The Centers for Medicare & Medicaid Services (CMS) appreciates the opportunity to review and 
comment on the Office of Inspector Generals (OIG) draft report on Medicare Advantage 
Organizations (MAOs) use of ordering provider National Provider Identifiers (NPIs) for 
program integrity purposes.  CMS is committed to working with MAOs to safeguard program 
integrity in Medicare Advantage, and recognizes that information that MAOs collect through 
encounter data can be an important part of that effort. 
Since the agency began collecting encounter data, CMS has been mindful of balancing 
immediate needs with long-term goals for use of the data, as well as provider and plan burden. 
For that reason, CMS initially focused on development of data necessary for payment purposes. 
However, CMS has continued to study the role that ordering and referring provider NPIs can 
play in Medicare Advantage program integrity. Though not currently a required submission, 
CMS has published guidance alerting MAOs to the importance of this information for program 
integrity purposes and encouraging the MAOs to monitor, evaluate, and take measures to ensure 
appropriate submission of ordering provider identifiers for Medicare Advantage encounter data 
based on the information provided in the memo.1 CMS also reminded MAOs that increased 
accuracy of referring provider identifiers will assist law enforcement in future program integrity 
efforts. 
In addition, CMS implemented a series of edits in December 2019 to ensure that, when 
populated, the rendering, referring, and ordering provider NPIs on encounter data are valid and 
active on the National Plan and Provider Enumeration System (NPPES). If an NPI is not found 
or is inactive on the NPPES, the encounter data are rejected. In March 2020, CMS reinforced this 
data integrity effort and implemented a series of edits to ensure that, when populated, the billing, 
rendering, referring, and ordering NPIs on encounter data are not on the CMS Provider 
Preclusion List. 
1 HPMS memo entitled Referring Provider Identifiers for Medicare Part C Durable Medical Equipment (DME) 
Encounters, January 17, 2020. 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity
OEI-03-19-00432            Appendix A | 9 CMS will continue to evaluate whether additional actions are needed to educate MAOs on the 
role this data can play in program integrity. 
OIGs recommendations and CMS' responses are below. 
OIG Recommendation 
CMS should encourage MAOs to perform program integrity oversight using ordering NPIs. 
CMS Response 
As OIG noted in its report, CMS released a memo in January 2020 encouraging MAOs to monitor, 
evaluate and take measures to ensure appropriate submission of ordering provider identifiers in 
encounter records.  CMS will consider whether additional education to MAOs on the role that 
ordering NPIs can play in program integrity oversight is needed.  
CMS thanks OIG for their efforts on this issue and looks forward to working with OIG on this 
and other issues in the future. 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity
OEI-03-19-00432                              Appendix A | 10  METHODOLOGY 
MAO Survey 
From February to March 2020, we administered an online survey to a stratified random 
sample of 200 MAOs.  We selected MAOs that (1) provided active plans as of 
January 1, 2017, and continued to be active in 2020;19 (2) offered coordinated care plans, 
medical savings accounts, or private fee-for-service plans;20 and (3) submitted 
2017 records to CMSs MA encounter data for DMEPOS, clinical laboratory services, 
imaging services, and/or home health services.21  The first stratum included all 33 of the 
MAOs that did not have an ordering NPI on any of their 2017 records in CMSs MA 
encounter data.22  We separated these 33 MAOs into their own stratum because we were 
particularly interested in learning about their procedures related to encounter records.  
The second stratum included 167 MAOs randomly selected from the 361 MAOs that had at 
least 1 ordering NPI on their 2017 records in CMSs MA encounter data.  We analyzed 
survey responses from 179 MAOs, 29 from the first stratum and 150 from the second 
stratum.  We reported our findings based on the responses of the sampled MAOswe did 
not project our results to the sample population.  This is the second OIG issue brief that 
analyzes data from this survey; the first was released in August 2020 and focused on the 
extent to which MAOs collect ordering NPIs and submit these identifiers to CMSs MA 
Encounter Data System. 
Limitations 
Most MAOs estimated the percentage of their MA encounter records on which providers 
submit ordering NPIs and other kinds of identifiers for each high-risk service. 
Standards 
We conducted this study in accordance with the Quality Standards for Inspection and 
Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency. 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432                   Methodology | 11   
 
ACKNOWLEDGMENTS AND CONTACT 
 
Acknowledgments 
Maria Johnson served as the team leader for this study.  Others in the Office of 
Evaluation and Inspections who conducted the study include Robert Kirkner.  Office of 
Evaluation and Inspections headquarters staff who provided support include 
Joe Chiarenzelli, Althea Hosein, and Christine Moritz.  Other Office of Inspector General 
staff who provided support include Marissa Baron and Julie Brown.  
This report was prepared under the direction of Linda Ragone, Regional Inspector 
General for Evaluation and Inspections in the Philadelphia regional office, and 
Joanna Bisgaier, Deputy Regional Inspector General. 
Contact 
To obtain additional information concerning this report, contact the Office of Public 
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found 
on the OIG website at oig.hhs.gov. 
Office of Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC 20201 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432                                             Acknowledgments and Contact | 12   
 
E E  NNDDNNOOTTEESS  
 
 
1 OIG, Media Materials: Nationwide Brace Scam, April 2019.  Accessed at https://www.oig.hhs.gov/newsroom/media-
materials/2019/bracescam/ on December 18, 2019. 
2 CMS, Operation Double Helix Takes Action in One of the Largest Health Care Fraud Schemes Ever Charged, September 2019.  
Accessed at https://www.cms.gov/About-CMS/Components/CPI/CPI-Spotlight-Archive on January 7, 2021. 
3 CMS, CMS Fast Facts, July 2020.  Accessed at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-
and-Reports/CMS-Fast-Facts on December 7, 2020. 
4 CMS, Financial Report Fiscal Year 2020, November 2020, p. 53.  Accessed at https://www.cms.gov/files/document/cms-
financial-report-fiscal-year-2020.pdf on December 7, 2020. 
5 42 CFR 422.503. 
6 CMS, Medicare Managed Care Manual, Pub. No. 100-16 (Rev. 110, 01-11-13), ch. 21,  50.6.9. Accessed at 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c21.pdf on August 21, 2020. 
7 CMS, Medicare Managed Care Manual, Pub. No. 100-16 (Rev. 110, 01-11-13), ch. 21,  50.6.6. Accessed at 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c21.pdf on August 21, 2020. 
8 CMS, Referring Provider Identifiers for Medicare Part C Durable Medical Equipment (DME) Encounters, January 2020. 
9 OIG, Medicare Advantage Encounter Data Show Promise for Program Oversight, but Improvements Are Needed, 
OEI-03-15-00060, January 2018. 
10 OIG, CMSs Encounter Data Lack Essential Information that Medicare Advantage Organizations Have the Ability to Collect, 
OEI-03-19-00430, August 2020. 
11 CMS uses the NPPES to assign NPIs, maintain information about health care providers with NPIs, and disseminate the NPI 
Registry and NPPES downloadable files.  See CMS, Medicare Learning Network, NPI: What You Need to Know, December 2016.  
Accessed at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/NPI-
What-You-Need-To-Know.pdf on June 1, 2020.   
12 These 81 MAOs both (1) reported that providers and/or suppliers submitted ordering NPIs on less than 90 percent of their 
MA encounter records for DMEPOS, and clinical laboratory, imaging, and home health services and (2) responded to our 
survey question about whether their lack of ordering NPIs hinders their performance of data analysis for MA program integrity 
oversight. 
13 By generally did not collect, we mean that an MAO did not collect other kinds of ordering provider identifiers on more than 
60 percent of encounter records for each high-risk service.  
14 CMS, Medicare Managed Care Manual, Pub. No. 100-16 (Rev. 110, 01-11-13), ch. 21,  50.6.9. Accessed at 
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/mc86c21.pdf on August 21, 2020. 
15 These 10 MAOs reported that providers and/or suppliers submitted ordering NPIs on 70 percent or more of their MA 
encounter records for DMEPOS and clinical laboratory, imaging, and home health services. 
16 These 14 MAOs reported that providers and/or suppliers submitted ordering NPIs on 70 percent or more of their MA 
encounter records for at least 1, but not all, of the 4 high-risk services. 
 
 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432                                          Endnotes | 13   
 
17 Of the 149 MAOs that (1) collect ordering NPIs on MA encounter records for DMEPOS, and clinical laboratory, imaging, and 
home health services and (2) responded to our survey questions about NPPES verification, 116 (78 percent) do not verify that 
ordering NPIs are present in the NPPES when they receive an encounter record.  Two of these 116 MAOs indicated that 
although they do not verify ordering NPIs are present in the NPPES when they receive an encounter recordthey may verify 
this information at another time. 
18 42 CFR  422.503. 
19 We used the 2017 Contract Information Extract from CMSs Health Plan Management System to determine MAOs with 
contract dates effective as of January 1, 2017, and we used the 2020 Contract Information Extract to confirm which MAOs 
continued to be active in 2020.  We then used the 2017 encounter data to stratify MAOs on the basis of their submission of 
ordering NPIs on 2017 encounter records.    
20 We did not include MAOs that offer cost plans, demonstration plans, or program of all-inclusive care for the elderly (PACE) 
organizations, as these may have different compliance program requirements. 
21 For encounter records with dates of service in 2017, we identified DMEPOS records as records with claim type code 4800; 
clinical laboratory records as records with claim type code 4700 and at least one service line with Berenson-Eggers Type of 
Service (BETOS) codes T1A through T1H; imaging records as records with claim type code 4700 and at least one service line 
with BETOS codes I1A through I4B; and home health records as records with claim type codes 4032, 4033, or 4034.    
22 Data elements for ordering NPIs are located in both the header and service-line portion of a service record.  For DMEPOS, 
clinical laboratory, and imaging records, we considered an encounter record to be missing an ordering NPI if it was missing 
from the header as well as from all the service lines.  For home health records, we considered an encounter record to be 
missing an ordering NPI if it was missing all of the three following data elements from the header and all service lines: 
(1) ordering NPI, (2) attending provider NPI, and (3) other provider NPI. 
Issue Brief: MAOs Are Missing Opportunities To Use Ordering Provider Identifiers To Protect Program Integrity 
OEI-03-19-00432                                          Endnotes | 14