Medicare Puts Greater Emphasis on Including NPIs on Part D Claims

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.

2 Responses to “Medicare Puts Greater Emphasis on Including NPIs on Part D Claims”

  1. 1 Kathleen Rothrock August 24, 2010 at 9:27 pm

    I have no problem with the NPI numbers, EXCEPT that about one out of every 5 or 6 names, I cannot find on the website!!! I live in the very NE corner of Arkansas, so I see lots of rxs from MO as well as TN. If a doctor’s NPI number cannot be found, what am I supposed to do???

    • 2 NCPA August 27, 2010 at 7:38 pm

      Based on our reading of the OIG report, we recommend that, if the prescriber’s NPI cannot be found by searching the National Plan and Provider Enumeration System (NPPES) database, pharmacies should instead include a valid DEA number on Part D claims, in lieu of the NPI. If neither a valid NPI nor a valid DEA number can be found, then the state license number should be used. Thank you.

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