A new compliance focus of Medicare’s has been to ensure that all pharmacy providers include a valid National Provider Identifier or NPI on all Part D drug claims. Community pharmacies can expect this drumbeat to continue and increase going forward.
The topic was highlighted in a hearing of a Senate Homeland Security and Governmental Affairs Subcommittee just before the August recess. Specifically, lawmakers examined the most recent U.S. Department of Health and Human Services’ Office of Inspector General (OIG) report, which looked at 2007 data and found that many claims carried invalid NPIs.
In recent years, community pharmacists have received mixed messages, to say the least, from Medicare and Part D plans regarding the inclusion of NPIs on claims, as opposed to DEA numbers and/or state license numbers. CMS didn’t start requiring the use of NPIs on Part D drug claims until well into 2007, the year OIG examined. One of the largest Part D plans did not start requesting provider NPIs until July 2008. And, to this day, one of the largest Part D plans’ provider services manual still allows for DEA numbers and/or state license numbers as a substitute when the NPI is not available.
Interestingly, according to the OIG report, “a single company that is a large pharmacy benefit manager and mail-order pharmacy accounted for the majority of PDE records that contained one of the top invalid prescriber identifiers.” Five of the top ten invalid identifiers appeared on individual claims for expensive drugs, with payment amounts of more than $10,000 per claim – the type almost exclusively dispensed via mail order and per the PBM’s requirements.
Regardless, going forward, any community pharmacy that wants to remain in the Part D program should ensure everything possible is done to include valid NPIs on drug claims.