Provider Directory Accuracy Monitoring and Use of the National Plan & Provider Enumeration System (NPPES)

By March 18, 2020CMS, Part C, Part D

On March 11, 2020 the CMS Part C and D User Call focused on Provider Directory accuracy and how the NPPES may support such accuracy.  In case you missed it, here is what you need to know.

What is NPPES?

NPPES is a downloadable database that has core data elements for provider directories at no cost to plans or providers.  The goal of NPPES is to improve provider directory accuracy while also reducing the burden on plans and providers.  NPPES usage is not required by anyone, but it is strongly recommended. CMS indicates that NPPES data is a valid source for provider directory data in audits of Medicare Advantage directory accuracy.

How do Plans Use NPPES?

Frequent updates are produced which will indicate there have been changes to the record. The changes are not evident and the plan must run a compare between the downloadable database and the update files.  Plans have to merge files to maintain a “master” and should confirm with the provider when they note differences in the data.  There is no standardized format for how data is currently entered into NPPES. https://download.cms.gov/nppes/NPI_Files.html

What Else Can Plans Do to Ensure Provider Directory Accuracy?

Provider education is key to ensuring NPPES has current information.   CMS is recommending that plans communicate with their network providers and advise providers to update NPPES.

Plans are encouraged to send the Medicare Learning Network article to providers.

Plans should let their providers know that they must ensure that they only include information for locations where beneficiaries can make appointments.  NPPES should reflect locations where a provider actively practices and sees beneficiaries versus locations where they may bill for services rendered (such as reading radiological reports, covering for another practitioner, etc.). Providers should understand that the information in NPPES does not correlate to billing Medicare for payment.

While CMS does want open and on-going communication with plans and providers regarding the directories, CMS does not require plans to conduct quarterly outreach.  They do, however, require plans to have accurate data.  CMS had previously published guidance stating that plans were required to conduct quarterly outreach, but CMS representatives confirmed during the call that the objective is accurate data, not frequency of contact with providers.  When CMS conducts monitoring, they will not ask plans for the frequency of contact.

When Will CMS Begin Monitoring?

CMS intends to begin monitoring directory access in May 2020.  CMS will not be evaluating whether or not the provider is accepting new patients as part of the oversight this year.  They will still be confirming that the provider accepts the Sponsor’s insurance product (contract and PBP level) since the provider is listed in that Plan’s directory.  CMS’ goal is to ensure that the beneficiary facing tool, the provider directory, is accurate.

What if there are Inaccuracies in NPPES?

If a plan has data which matches what is in NPPES (which has been certified after January 1, 2020), then the plan will not be cited for non-compliance for data accuracy this year.  The plan will be required to reach out to the provider and require the provider to update NPPES.

Use of NPPES should be considered as another tool to assist Sponsors with ensuring they have accurate data but should not be used as the only source of truth.  Sponsors should not copy the data from NPPES and put in their system. With all Sponsors working to educate providers about having accurate information listed in NPPES all plans can benefit.

Need Help Reviewing Your Provider Directory Accuracy?

BluePeak conducts Provider Directory Assessments and Audits to help Plans ensure their directories are accurate and their processes will support accuracy over time.  BluePeak can audit your directory, support provider communications and make recommendations for a successful communication process.  Contact us today for a free consultation.