type: other

text: b'Department of Health and Human Services\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\nCARRIER ASSIGNMENT OF MEDICARE \n\n PROVIDER NUMBERS \n\n\n\n\n\n .\n\n\n\n\n Richard P. Kusserow\n INSPECTOR GENERAL\n\n APRIL 1992\n\x0c OFFICE OF INSPECTOR GENERAL\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, as\namended, is to protect the integrity of the Department of Health and Human Services* (HHS)\nprograms as well as the health and welfare of beneficiaries served by those programs. This statutory\nmission is carried out through a nationwide network of audits, investigations, and inspections\nconducted by three OIG operating components: the Office of Audit Services, the Office of\nInvestigations, and the Office of Evaluation and Inspections. The OIG also informs the Secretary of\nHHS of program and managementproblems, and recommends courses to correct them.\n\n OFFICE OF AUDIT SERVICES\n\nThe OIG\xe2\x80\x99s Offtce of Audit Services (OAS) provides all auditing services for HHS, either by\nconducting audits with its own audit resources or by overseeing audit work done by others. Audits\nexamine the performance of HHS programs and/or its grantees and contractors in carrying out their\nrespective responsibilities, and are intended to provide independent assessmentsof HHS programs and\noperations in order to reduce waste, abuse and mismanagementand to promote economy and\nefficiency throughout the Department.\n\n OFFICE OF INVESTIGATIONS\n\nThe OIG\xe2\x80\x99s Office of Investigations (01) conducts criminal, civil, and administrative investigations of\nallegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by\nproviders. The investigative efforts of 01 lead to criminal convictions, administrative sanctions, or\ncivil money penalties. The 01 also oversees State Medicaid fraud control units which investigate and\nprosecute fraud and patient abuse in the Medicaid program.\n\n OFFICE OF EVALUATION AND INSPECTIONS\n\nThe OIG\xe2\x80\x99s Office of Evaluation and Inspections (OEI) conducts short-term management and program\nevaluations (called inspections) that focus on issues of concern to the Department, the Congress, and\nthe public. The findings and recommendations contained in the inspections reports generate rapid,\naccurate, and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental\nprograms.\n\nEntitled \xe2\x80\x9cCarrier Assignment of Medicare Provider Numbers,\xe2\x80\x9d this report describes and assessesthe\nprocess by which Medicare carriers assign provider numbers. This report was prepared under the\ndirection of Ralph Tunnell, Regional Inspector General of Region VI, Office of Evaluation and\nInspections, and Chester B. Slaughter, Deputy Regional Inspector General. Participating in this\nproject were the following OIG personnel:\n\nRegion VI, OEI Headquarters, OEI\n\nKevin Golladay Wayne Powell\nLeah Bostick\nDouglas Lauver\n\x0c Department of Health and Human Services\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\nCARRIER ASSIGNMENT OF MEDICARE \n\n PROVIDER NUMBERS \n\n\n\n\n\n Richard P. Kusserow\n INSPECTOR GENERAL\n\n OEI-0643940871\n\x0c EXECUTIVE SUMMARY\n\nPURPOSE\n\nThis report describes and assessesthe process by which Medicare carriers assign provider\nnumbers.\n\n\n\nMedicare carriers assign provider numbers to qualified providers of Part B services who\nfurnish services or supplies to Medicare beneficiaries. The numbers are used in processing\nclaims and establishing Medicare pricing and utilization profiles. To obtain a provider\nnumber from a carrier, providers typically complete the carrier\xe2\x80\x99s provider number application\nform and meet criteria specified by Medicare regulations. Carriers are responsible for\ndetermining if providers meet Medicare criteria through its number assignment process.\n\nMETHODOLOGY\n\nThis inspection consisted of several phases. First, we conducted a review of relevant Health\nCare Financing Administration (HCFA) policies and Medicare laws and discussions with\nHCFA staff. Next, we requestedcopies of all application forms used by carriers to obtain\ninformation prior to assigning a number to a provider. To test assignment procedures, we\nreviewed carrier documentation supporting the recent assignment of numbers to more than\n240 providers. Specifically, 40 carriers were asked to supply file documentation for the most\nrecent applicant assigned a provider number for seven different types of providers (solo\nphysician, physician group or clinic, chiropractor, durable medical equipment supplier,\nambulance, certified registered nurse anesthetist, and physician assistant). Next, we\nsurveyed 38 carrier personnel responsible for assigning numbers. Additionally, we discussed\nprovider number assignment vulnerabilities with carrier program integrity staff (25\nrespondents) and reviewed files of providers with overpayments selected from the 12/01/89\nHCFA Physician/Supplier Overpayment Report. Finally, we reviewed Management\nImplication Reports (MIRs) prepared by the Office of Inspector General\xe2\x80\x99s Office of\nInvestigations (01) suggesting provider number assignment problems and concerns. We\ncontacted each of the eight 01 regional offices to obtain case experience and perspectives and\nto discuss prior MIRs.\n\nFINDINGS\n\nHCFA\xe2\x80\x99s Direction and Oversight of Carrier Provider Number Assignment Procedures\nare Inadequate.\n\n The HCFA provides insufficient practical direction to carriers concerning the provider\n number assignment function. Specifically, HCFA has not clearly defined the methods\n or depth of understanding and testing to ensure adequate knowledge about a provider\n before a number is assigned. Our review of carrier instructions in the Medicare\n\n\n i\n\x0c Carrier Manual (MCM) identified several issuesnot adequately addressed. For\n example, what is a carrier\xe2\x80\x99s responsibility to understandand determine legal\n authorization to practice? This lack of direction and oversight contributes to carrier\n provider number assignment weaknessesand vulnerabilities.\n\nCarrier Provider Number Assignment Weaknesses and Vulnerabilities Exist.\n\n0 Many cartiers do not adequately document provider number assignment procedures.\n\n0 Cartiers obtain or maintain too little provider infomration.\n\n Application forms often do not obtain sufficient information from providers.\n\n Little or no businessownership information is required by carriers.\n\n Ironically, the least regulated providers (e.g., durable medical equipment) are\n the least scrutinized by carriers when applying for a provider number.\n\n Carrier application forms are often missing or not readily retrievable.\n\n0\t Some carriers fail to verkif provider qualifications prior to assignment of a prwider\n number.\n\n Some carriers do not validate provider credentials (e.g., State license).\n\n Many carriers allow reassignmentof benefits without determining if the\n reassignment meets Medicare legal requirements.\n\n0 Weak provider number assignment procedures contribute to progmm vulnembilities.\n\n Carrier methods or practice to identify all numbers assigned to a provider are\n inadequate.\n\n Providers can manipulate multiple numbers and jurisdiction rules to increase\n reimbursement or avoid detection of abusive practices.\n\n Most carriers do not uniquely identify physician assistantsand thus, cannot\n perform adequateutilization review.\n\n Carrier computer records maintained on providers need improvement.\n Specifically, provider name irregularities exist and provider State license\n numbers are missing or inaccurately entered.\n\n0\t Many carriers assign additional provider numbers solely for a provider\xe2\x80\x99s\n bookkeeping convenience.\n\x0cOIG Recommendations and HCFA Action Plan\n\nIn our draft report, we made specific recommendations to correct the weaknesses cited\nabove. (They are included verbatim on page 20 of this final report.) The HCFA provided\nwritten comments on the draft report. More importantly, however, HCFA itself has\nundertaken several major initiatives to address these problems and related issues raised in a\nprior OIG report entitled \xe2\x80\x9cCarrier Maintenance of Medicare Provider Numbers.\xe2\x80\x9d We and\nHCFA, therefore, worked together to reach agreement on an action plan to improve the\nprovider number process. In light of this, we are no longer designating the problems cited in\nthis and the prior report as a material weakness. The following is the agreed upon action\nplan:\n\n\n MEDICARE PROVIDER NUMBERS\n\n ACTION PLAN\n\n\n\n HCFA will issue a modification to the Medicare Carrier Manual which will:\n\n Clearly state that carriers have a responsibility to ensure the integrity of\n provider numbers and to ensure that only those practitioners and providers\n with legal authority to practice are given and may retain provider\n numbers.\n\n Require carriers to stay abreast of changes in relevant laws and regulations\n concerning medical practice requirements.\n\n Require carriers to make every reasonable effort to receive on an ongoing\n basis information from State licensing authorities and other appropriate\n bodies about the currency of licenses.\n\n Require carriers to maintain provider number applications for at least six\n years after deactivation of the number (the period needed to facilitate\n investigations, prosecutions, and sanctions). This requirement pertains to\n applications from both health professionals and provider entities which are\n discussed separately below.\n\n Require carriers to periodically purge from their lists of approved numbers\n those that have been inactive and for professionals or entities who no\n longer have valid licenses required by the State.\n\n\n HEALTH PROFESSIONALS\n\n HCFA will continue to vigorously implement and enforce compliance with the\n provisions of the recently established UPIN system for Medicare physicians\n\n .. .\n Ill\n\x0c(which includes medical doctors, osteopaths, dentists, chiropractors, podiatrists,\nand optometrists).\n\nHCFA will explore the extension of the UPIN system to cover all limited licensed\nprofessionals that can bill Medicare directly. HCFA will provide a schedule for\ndoing so. This would include clinical psychologists, clinical social workers, and\ncertified registered nurse anesthetists.\n\nAll registry data will be made readily available to all carriers on January 1. 1992.\n(Procedures prior to that date only allowed carriers to obtain information about\nprofessionals within their own jurisdiction.)\n\nHCFA will monitor and ensure compliance of the carriers with their responsibili\xc2\xad\nties regarding provider numbers as set forth in the Medicare Carrier Manual. (See\nGENERQL section above.)\n\n\n\n\nHCFA will implement a major reform of the carrier process for dealing with\ncertain \xe2\x80\x9csuppliers\xe2\x80\x9d. (Here, the term is meant to include entities which provide:\ndurable medical equipment, routine and readily available supplies, prosthetics,\northotics, immunosuppressant drugs, and ESRD services.)\n\nSome of the more important features of this initiative are:\n\n Four regional carriers will be responsible for establishing supplier numbers\n and processing all Medicare claims for the above mentioned supplies.\n\n A clearinghouse which will contain information from supplier number\n applications and whose data will be accessible to all of these carriers.\n\n A standard application form which includes information to enable the\n carriers to identify each unique entity, their ownership, related entities,\n and sanctions.\n\n The application form will contain a signed statement of the applicant\n attesting to the veracity of all information provided and acknowledging\n responsibility for false or misleading statements.\n\n The carriers will be responsible for processing all claims for supplies\n furnished to beneficiaries who reside within their jurisdiction.\n\nHCFA plans to implement this major reform within the next two years.\n\nThe statement of work for the contract under which these carriers will function\nwill include a clear statement of responsibilities concerning supplier numbers\nsimilar to those listed in the GENERAL. section above.\n\n\n iv\n\x0cThese carriers will be required to use the information in the clearinghouse to\nscreen applicants for supplier numbers for such things as relationships to\nsanctioned individuals or business or to businesses suspected of fraud or abuse.\n\nThe carriers will verify the accuracy and completeness of the information\ncontained in supplier number applications and files, and will identify and take\nappropriate action against problem suppliers.\n\nHCFA will vigorously monitor compliance of these carriers with those contractual\nprovisions related to the application for, granting of, and maintenance of supplier\nnumbers. HCFA is determining how the performance of these carriers will be\nevaluated.\n\nHCFA will require carriers to reenroll all suppliers every two years to insure that\nthe ownership and operating information remains current.\n\nIn the future, HCFA will extend this system to cover other supplier entities such\nas independent physiological labs, magnetic resonance imagers, and ambulance\ncompanies. In the meantime, however, these other supplier entities will be\nrequired to use a standard application form with provisions for identifying\nownership and sanctions, and including the signed veracity certification.\n\n\n\n\n V\n\x0c TABLEOFCONTENTS\n\nEXECUTIVE SUMMARY\n\nINTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1\n\n\n Purpose. .................................................... 1 \xe2\x80\x99\n\n Background. ................................................. 1\n\n Methodology. ................................................ 4\n\n\nFINDINGS ,...,................a........................ 6\n\n\n HCFA\xe2\x80\x99s Direction and Oversight of Carrier Provider Number Assignment \n\n Procedures are Inadequate . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 6\n\n\n Carrier Provider Number Assignment Weaknesses and Vulnerabilities Exist . . . . . . 7\n\n\n Many carriers do not document provider number assignment procedures . . . . . 7\n\n\n Carriers obtain or maintain too little provider information . . . . . . . . . . . . . . . . 7\n\n\n Some carriers fail to verify provider qualifications . . . . . . . . . . . . . . . . . . . . 10 \n\n\n Weak provider number assignment procedures contribute to program\n vulnerabilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 \n\n\n Many carriers assign additional provider numbers solely for a provider\xe2\x80\x99s \n\n bookkeeping convenience . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . 17 \n\n\nRECOMMENDATIONS . . , . , . , . . . , . . , . . . . . . . . . . . . . . . . . . . . . . . 20 \n\n\nHCFA RESPONSE AND ACTION PLAN . . . . . . . . . . . . . . . . . . . . . . . . . . 22 \n\n\nAPPENDICES . . . . . . . . . . . . . . . . . . . . . ..a.................. 24 \n\n\n Appendix A: Part B Providers\n Appendix B: Carrier Respondents and State Jurisdictions\n Appendix C: \t Examples of Information Requested on Application Forms for\n DME and Physicians\n Appendix D: Claim Jurisdiction Rules Simplified\n Appendix E: Examples of Carrier Methods of Processing PA Claims \n\n Appendix F: Physician Registry Activity by Carrier \n\n Appendix G: Carrier Provider Number Assignment Activity \n\n Appendix H: Carrier Supplied Counts of Various Types of Providers \n\n\x0c INTRODUCTION\n\nPURPOSE\n\nThis report reviews the processby which Medicare carriers assign provider numbers.\nSpecific objectives were to:\n\n 1) describe and assesscarrier provider number assignment procedures and\n 2) discuss vulnerabilities in these procedures.\n\nA recently released report, \xe2\x80\x9cCarrier Maintenance of Medicare Provider Numbers\xe2\x80\x9d (OEI-06-\n89-00870), prepared in conjunction with this inspection, describes and assesseshow carriers\nmaintain provider numbers once assigned.\n\nBACKGROUND\n\nCarriers are private insurance companies acting under contract with the Health Care\nFinancing Administration (HCFA) to processclaims by beneficiaries and providers for\nservices or supplies covered under Medicare Part B. While most Stateshave jurisdiction for\none State, a few carriers handle more than one State. The HCFA provides direction to the\ncarriers on payment matters and is ultimately responsible for ensuring carriers adhere to\napplicable program policies and procedures.\n\nIn fiscal year 1989, Part B covered approximately 32 million enrollees and paid benefits of\nabout $37 billion for over 407 million claims. With such an enormous expenditure of\ngovernment funds and volume of claims to process, it is imperative carriers ensure payments\nare 1) made only for services covered under the Medicare program, 2) medically necessary\nunder recognized standardsof medical care, 3) actually rendered to eligible Medicare\nbeneficiaries, 4) reimbursed at appropriate payment levels, and 5) delivered by providers\nmeeting standardsrequired by State and Federal law.\n\nState Licensure and Certification\n\nLicensing and certifying providers are primarily State functions. Individuals or entities must\nmeet State criteria to obtain and maintain a license or certification. The States are\nresponsible for regulating the practice of those they have licensed or certified. Statesare\nalso responsible for ensuring these providers meet standardsof professional competence and\npersonal integrity considered necessaryto protect the public.\n\nThe State license or certificate demonstratesthe provider satisfies the State\xe2\x80\x99s established\nstandardsin such areas as education, experience, and ethics. Once licensed or certified, the\nprovider must then comply with the State\xe2\x80\x99s prescribed standards for the practice of the\nprofession and any other specified criteria for maintaining a license or certification.\n\x0cFailure to meet these requirements may result in the State suspendingor restricting the\nlicense or certificate to provide services. When a provider loses the legal authority to\npractice, no seNices of the provider are covered by Medicare.\n\nFedeml Interest in Medical Provider Qual$htions\n\nThe Federal government has shown a strong interest in ensuring medical providers have\nadequatequalifications. The Consolidated Omnibus Budget Reconciliation Act of 1985\nmandated a physician registry and the use of a unique practitioner identifier number (UPIN)\nto prevent duplicate payments for hospital-basedphysicians and interns under the Medicare\nprogram and to more accurately track Federally-sanctioned physicians. The HCFA oversees\nthe registry.\n\nAnother database,the National Practitioner Data Bank, recently began operation monitoring\nState licensed health practitioners. This data bank maintains records of all adverseactions\n(e.g., license revocation, malpractice) taken against medical providers and entities after the\nopening of the data bank. The data bank was authorized by the Health Care Quality\nImprovement Act of 1986 (P.L. 99-660, title IV) and the Medicare and Medicaid Patient and\nProgram Protection Act of 1987 (P.L. 100-93, section 5). This databank is monitored by the\nPublic Health Service (PHS).\n\nThese two databasesenhancethe Federal government\xe2\x80\x99s ability to monitor providers.\nHowever, responsibility for ensuring Medicare providers meet licensing and other\nrequirements specified by State and Federal law rests ultimately with carriers.\n\nCarrier Ptvvider Number Assignment\n\nCarriers assign unique identification numbers (hereafter referred to as provider numbers) to\nproviders of Medicare Part B reimbursable servicesor supplies. Provider numbers are used\nin processing claims for services rendered to Medicare beneficiaries. The number is also\nused in establishing Medicare pricing and utilization profiles. If the provider of services\ndoes not have a provider number, payment probably will not be made for services. To\nobtain a provider number from a carrier, providers must follow the carrier\xe2\x80\x99s application\nprocedures. This generally involves completion of the carrier\xe2\x80\x99s provider number application\nform. Additionally, the provider must meet Medicare requirements. Carriers assumeall\ncosts for assigning and maintaining provider numbers.\n\nThe accuracy and effectiveness of a carrier in meeting applicable Medicare responsibilities is\ndependent in large measure upon its provider number assignmentprocess. As described thus\nfar, the provider number assignment processappearsto be relatively simple. However, its\nsimplicity disguises its importance; failure to adequately determine a provider\xe2\x80\x99s qualifications\nand payment variables can have significant consequencesfor the Medicare program in fraud,\nabuse, or error. Prudence and common sensedictate provider numbers should be guarded\nwith every reasonablediligence.\n\x0c&ledicare Reouirements \n\n\nPrior to the issuanceof a provider number, carriers need to establish the following: \n\n\n Provider What provider(s) renders services or supplies?\n Identification\n\n Credential Does the provider meet Medicare qualifications (e.g., legally authorized by the\n Verification State where services are rendered)?\n\n Exclusion from Is the provider prohibited from participating in the Medicare program?\n Participation\n\n Carrier Claim What carrier has jurisdiction for claims submitted by the provider7\n Jurisdiction\n\n Carrier Pricing What method of reimbursement applies (e.g., fee schedule)? What is the\n Rules correct customary and prevailing charge to use? What is the specialty of the\n provider7 Is the provider Medicare participating or not?\n\n Reassignment Will the payment go to the provider of services or to another (e.g., employer)?\n Limitations If so, will the recipient of monies meet Medicare reassignment limitations?\n\n Reporting What information is required for submission of a record by carriers to the\n Requirements Physician Registry and to HCFA?\n\n Utilization Review What review and profiling parameters should apply to this provider7\n\n\nFurther, Medicare law and policy differentiates between two very different types of\napplicants for Medicare provider numbers:\n\n 0\t Providers of services or supplies - entities and individuals actually performing\n services or nrovidinp sun&es to beneficiariq.\n\n Carriers are responsible for verification of any prerequisite credentials\n (e.g., license, equipment, seller\xe2\x80\x99s permit, etc.) specified by State, local, or\n Federal law. Medicare law and policy place differing requirements on\n different types of providers. Generally, a provider of services must be legally\n authorized to provide the services by the State where services are rendered.\n For example, Medicare law requires covered physician services be rendered by\n licensed physicians who are \xe2\x80\x9clegally authorized to practice\xe2\x80\x9d (Social Security\n Act, Section 1861) by the State where the services are rendered.\n\n Although qualifications for other Medicare provider types may include State\n licensure or certification, some providers (e.g., ambulance companies) are\n required to meet additional education, work experience, staff, or equipment\n needs in order to participate in the Medicare program.\n\x0c However, this is not to say every provider type must meet specified criteria.\n Some providers, such as durable medical equipment @ME), generally\xe2\x80\x99 do not\n have to meet any criteria except to possessa Social Security number or an\n employer identification number.\n\n Beyond the need to determine applicant qualifications, there are a variety of\n payment and program integrity responsibilities tied to data collection and\n computer analysis of the service provider\xe2\x80\x99s Medicare experience.\n\n 0\t Billers of services and supplies - entities and organizations billin? for the\n services or sunnlies nrovided.\n\n Carriers must determine if the entity requesting payment meets Medicare\n requirements. If the individual or entity (partnership, professional association,\n clinic, etc.) billing and receiving payment did not actually provide the service\n or supply, carriers must establish the relationship between the biller and\n performer of services. Also, Medicare requires carriers to ensure payment is\n not made to entities or individuals excluded from participation in Medicare.\n Finally, carriers should have sufficient information about the billing entity\n (owners, agents, officers, etc.) in the event questions arise concerning payment\n or if overpayments need to be recovered from liable individuals or entities.\n\nIn addition to the concern over provider number assignment, the areasaddressedin this\nreport are considered especially timely in light of physician payment reforms, establishment\nof the Physician Registry, and HCFA\xe2\x80\x99s interest in ensuring the quality of providers of\nMedicare services.\n\nMETHODOLOGY\n\nThis inspection consisted of several phases. First, we conducted a review of relevant HCFA\npolicies and Medicare laws and discussionswith HCFA staff. Next, we requestedcopies of\nall application forms used by carriers to obtain information prior to assigning a number to a\nprovider. To test assignment procedures, we reviewed carrier documentation supporting the\nrecent assignment of numbers to more than 240 providers. Specifically, 40 carriers were\nasked to supply file documentation for the most recent applicant assigneda provider number\nin the following categories:\n\n 0 Solo-practice physician \n\n 0 Physician group or clinic \n\n 0 Chiropractor \n\n 0 Ambulance \n\n 0 Durable medical equipment \n\n 0 Physician assistant (PA) \n\n 0 Certified registered nurse anesthetist (CRNA) \n\n\n For this inspection, we excluded any review of providers certified by HCFA for \n\n participation in Medicare. This was done to limit the scope of work. Additionally, \n\n\n 4\n\x0c this was done in recognition of State survey and certification agency review of the\n provider\xe2\x80\x99s credentials and HCFA\xe2\x80\x99s assignmentof provider numbers rather than carrier\n assignment of provider numbers to many of these types of providers. (See Appendix\n A for a list of Part B providers and those certified by HCFA.)\n\nNext, we visited three carriers and mailed surveys, with telephone followup, to 35 others.\n(See Appendix B for a complete list of carrier respondentsand Statejurisdictions.) The 38\nrespondentswere carrier personnel responsible for assigning numbers.\n\nAdditionally, we discussednumber assignmentvulnerabilities with carrier program integrity\nstaff (25 respondents)and reviewed files of providers with overpayments selected from the\n12/01/89 HCFA Physician/Supplier Overpayment Report.\n\nFinally, we reviewed Management Implication Reports (MJRs) prepared by the Office of\nInspector General\xe2\x80\x99s Office of Investigations (01) suggestingprovider number assignment\nproblems and concerns. We contacted the eight 01 regional offices to obtain caseexperience\nand perspectives and to discussprior MIRs.\n\x0c FINDINGS \n\n\nHCFA\xe2\x80\x99s Direction and Oversight of Carrier Provider Number Assignment Procedures\nare Inadequate.\n\nThe HCFA provides insufficient practical direction to carriers concerning the provider\nnumber assignment function. Specifically, HCFA has not clearly defined the methods or\ndepth of understanding and testing to insure adequateknowledge about a provider before a\nnumber is assigned (e.g., DME). Our review of carrier instructions in the Medicare Carrier\nManual (MCM) identified several issuesnot adequately addressed. Among them are:\n\n How are carriers to determine legal authorization to practice?\n\n What is the minimum information to be obtainedfrom providers by carriers?\n\n What identifying provider information should be maintained in the carrier\xe2\x80\x99s computer system? _\n\n How is a physician \xe2\x80\x98s specialty to be determined?\n\n Should providers complete carrier application forms? Should they be maintained?\n\n When is it appropriate to assign multiple provider numbers to the sameprovider?\n\n What carrier controls should existfor the utilization review of providers having multiple\n numbers?\n\nInsufficient direction and oversight has contributed to carrier assignment vulnerabilities.\nTwenty of the carrier provider number assignmentpersonnel contacted recognize weaknesses\nand believe HCFA should play a prominent role by providing more guidance concerning\nnumber assignment policies. Some areas noted by carriers include the need for:\n\n More \xe2\x80\x98policy issued regarding suppliers - establishing guidelines for qualifying as a\n DME supplier, ownership questions, etc. \xe2\x80\x9d\n\n More specific guidance on \xe2\x80\x9cjurisdiction, multiple ojfice settings, and clinics. \xe2\x80\x9d\n\n \xe2\x80\x9cNational standards for non-physicians (e.g., DME). \xe2\x80\x9d\n\n \xe2\x80\x9cClearer guidelines regarding physicians under contract with groups/clinics and\n other physicians meeting employee status requirements. \xe2\x80\x9d\n\n \xe2\x80\x9cCertification guidelines for physiological laboratories. *\n\n \xe2\x80\x9cGuidance when it is appropriate to have more than one number. \xe2\x80\x9d\n\x0cA critical and fundamental point of control for correct payment and detection of abusive\nproviders occurs during the provider number assignmentprocess. While the Physician\nRegistry is certainly a step in the right direction, many weaknessesand vulnerabilities still\nexist in provider number assignment procedures. These weaknessesor vulnerabilities could\nresult in adverse monetary or quality of care consequencesfor the Medicare program or\nbeneficiaries.\n\n\nCarrier Provider Number Assignment Weaknesses and Vulnerabilities Exist.\n\nMany caniers do not adequately document provider number assignment pnwdures.\n\nNearly 50 percent of carriers (18) have no formal written internal procedures for number\nassignment. A lack of written instructions on provider number assignment may complicate\ntraining of new staff and may promote inconsistency in the provider number assignment\nprocess. Additionally, a lack of documented procedures may complicate review by HCFA\nto determine carrier implementation of manual instructions affecting provider number\nassignment.\n\nCbniers obtain or main&in too little provider infotmation.\n\n0 Application forms often do not obtain sufficient information from providers.\n\nCarrier applications represent the minimal information required to determine who the\nprovider is and what pricing parameters apply (locality, specialty, hospital based, etc.). The\napplications used by carriers raise concern about the rigor with which carriers scrutinize\nproviders. This concern is based on the fact that many carrier provider number application\nforms obtain little information from provider number applicants. (See Appendix C for a\nlisting of the types of questions being asked on application forms for DME and physicians).\n\nMany carriers limit applications to a few basic claims questions (name, tax number, address,\ntype of provider, and license number); few ask for additional information. (See Figure 1 for\nexamples of questions asked by carriers.) By not asking questions beyond basic claims\ninformation, a carrier may make incorrect assumptions about the provider\xe2\x80\x99s situation.\n\nAdditionally, several carrier application forms lack professionalism. Specifically, the\napplication form may not be professional in appearance(i.e., typeset or desktop published).\nAlso, questions may not be 1) presented in a logical sequenceor 2) clear in meaning.\n\x0c Carriers Require Little Information From Providers\n ,,.:.... . ... ...,:,.:.,... ., ,.:..,. ., .,.,\n :::.:.:.\n ,.,.? : j ........\xe2\x80\x9d .i ::\xe2\x80\x99\xe2\x80\x98...:...:.:.:.:.\xe2\x80\x99\n :\xe2\x80\x99\n .:i:;:..\n ........ ..\xe2\x80\x98. .\xe2\x80\x9c.\xe2\x80\x9d\n ..:.:.. :,,,,+:.:.::~::.~&f*~\n .:..\n :.:.:..\n ....\n \xe2\x80\x98.G*&&\n .Cti+::\n D&\n :.Pe.tietit\n and\n -\n -\n\n\n 27 71%\n Do you use a billing agency? 6 16%\n What other txovider numbers with thus earner do VW have? IS RmL\n\n\n\n WQrShnfiage Area?\n\n\n\n\n ness.\n\n\n\n\n tions? \t i I-,\xc2\xad\n 8 22%\n 6 16%\n I Will VW billina for\n _ ~- -- -...... natkant?: .WWw..W\xe2\x80\x9d\n .-. r-..-..I hwtad in nthnr\n ..I VU,\xe2\x80\x9c, ct3ta.s\n e,a,.zai c)\n I Owner\xe2\x80\x99s name?\n\n I a, I\n ?r earner unsdlctlons? al 3\n\n\n\n\n Figure 1\n\n0 Little or no businessownership information is required by carriers.\n\nOver one-third of carriers reviewed (15) do not routinely ask for DME ownership\ninformation on the application for assignment of a provider number. A slightly higher\nnumber (22) of carriers do not routinely ask ambulance companies to identify owners. Only\none carrier requires ownership information from clinics or professional associations.\n\nA lack of ownership information leaves the carrier in a position of not being able to\ndetermine if the company is controlled or owned by an individual, group of individuals, or a\n\n\n 8\n\x0cbusinessentity who has been convicted of a criminal or sanctionable offense related to\nparticipation in Medicare and Medicaid.\n\nAlso, failure to obtain ownership allows providers the opportunity to escapecarrier review of\nprovider numbers not identified with the owner(s). For example, 12 carriers noted instances\nduring the past year where businessentities with overpayments or who were on prepayment\nor postpayment review simply ceasedusing the provider number for the troubled business\nand obtained a new provider number from the same or other carriers. Some providers may\neven use the same employer identification number @IN), social security number (SW), or\naddressbut simply change their name on the new application for a new provider number.\nWithout ownership information, alteration of any identifying information (name, EIN,\naddress)can disguise the provider enough to obtain a new provider number. Thus, a\nprovider may easily escapecarrier controls.\n\nEven when ownership information is required, many carriers limit ownership questions to a\nsingle owner\xe2\x80\x99s name. Very few carriers require the supplier to identify all owners,\nindividuals with financial interest, directors, and/or officers.\n\nCarriers have long been criticized for not requiring businessesto disclose ownership. In\nresponseto this weakness, Congresshas passedlegislation (Omnibus Budget Reconciliation\nAct of 1990, P.L. 101-508) providing the authority for carriers to obtain ownership and\nfinancial interest information from suppliers and mobile labs. Although implementing\nregulations are not yet written by HCFA, ownership information should enhancecarrier\nefforts to track problem suppliers. However, carriers must be required to obtain and use\nownership information if the gathering of such information is to have a real impact on\ndeterring fraud and abuse.\n\n0\t Ironically, the least regulated providers are the least scrutinized by carriers when\n applying for a provider number.\n\nSome nonphysician suppliers are essentially unregulated by State and Federal agencies.\nThese entities provide such products as DME, oxygen*, prosthetics, and other similar types\nof supplies. The HCFA does not require carriers to obtain specific information from these\nproviders. As a consequence,only a few carriers ask for additional application information\nbeyond basic information (e.g., name, address, tax number, phone number) to ensure a\ncarrier\xe2\x80\x99s understanding of the provider\xe2\x80\x99s request and situation. Additional information may\nbe neededto correctly determine payment or utilization review parameters.\n\nSome areas not fully explored by all carriers involve ownership, carrier jurisdiction, and the\nprovider\xe2\x80\x99s present and past Medicare activity. Such information is crucial as a first step in\ndeterring providers from \xe2\x80\x9cgaming\xe2\x80\x9d the program (a provider\xe2\x80\x99s efforts to maximize\nreimbursement through fraudulent or abusive practices).\n\n0 Carrier application forms are often missing or not readily retrievable.\n\nWhile few (5) carriers reported not requiring completed applications prior to provider\nnumber assignment, many carriers requiring completed applications do not have applications\n\n 9\n\x0c(hardcopy or microfiche) for many active providers. For example, Aetna of Georgia\nestimates only 20 percent of providers have applications on file. The carrier reports, during\nthe transition from the prior carrier to Aetna (1989), files were \xe2\x80\x9creceived incomplete.\xe2\x80\x9d\nEquicor (North Carolina) estimates from 15 to 20 percent of applications are missing. Like\nAetna, Equicor attributes this to the previous carrier which did not always require completed\napplications. Another carrier, Blue Cross and Blue Shield of Alabama, estimates 15 to 25\npercent of applications are missing becausethe carrier\xe2\x80\x99s \xe2\x80\x9capplication process has been in\nplace for only 3 years.\xe2\x80\x9d\n\nThe application document acts as a source record if any questions arise concerning possible\nmisrepresentation on the part of the provider. According to 01 investigators and HCFA,\nsuch a record is often very important to criminal casesand civil recovery by the carrier and\nHCFA.\n\nAdditionally, in our review of documentation supporting providers recently assignedprovider\nnumbers, we found some key documentation was lacking. For example, the carrier may\nhave reported verification of the provider\xe2\x80\x99s license was done by requesting a copy of the\nlicense from the provider; however, no license was present in the file documentation.\nAdditionally, if telephone contact with the licensing board was made, most carriers failed to\ndocument the call. Our review of documentation for physicians recently assigneda provider\nnumber, revealed only 19 carriers had adequately documented their method of licensure\nverification,\n\nSome caniem fail to Ye@,&pmvider q@ficahns prior to assi@unent of a provider\nnumber.\n\n0 Some carriers do not validate provider credentials.\n\nSeveral carriers do not validate or document the credentials of Part B providers prior to\nprovider number assignment. (SeeFigure 2.) In direct contradiction to Part 4 of the MCM,\nsix carriers make no attempt to validate a solo practice physician\xe2\x80\x99s license. The MCM\n(1001.3) specifically states, at a minimum, carriers wilI \xe2\x80\x9cverify all physician submitted data\nwith the appropriate State licensing board to determine if the physician is registered and\nlicensed to practice.\xe2\x80\x9d An additional three carriers do not validate credentials of a physician\nin a group or clinic. Again, these carriers are not in compliance with MCM instructions\nwhich specifically require credential verification \xe2\x80\x9cregardless of whether the physician has a\nsolo or group practice. \xe2\x80\x9d\n\nCarriers report validation is not done primarily becauseof a lack of resourcesor funding for\nthis activity. None of the carriers attributed their failure to validate a medical physician\xe2\x80\x99s\nlicense to lack of cooperativenessby the applicable State medical board. During our\ndiscussions with these State medical boards, each reported it could and would respond in a\ntimely manner to carrier attempts to verify a license.\n\nThe MCM does not specify the methods by which carriers must verify provider credentials.\nAs a consequence,the methods used differ between carriers. Most carriers verify a\nprovider\xe2\x80\x99s license and registration from a board listing of licensed providers. Other carriers\n\n 10\n\x0ceither contact boards directly or request a copy of the license or registration from the\nprovider. (See Figure 2.)\n\n\n\n Provider\n\n\n\n\n I Two caniera requimd no nwihttion since State does not recognke PAS Source: Camw Survey (37 respondents)\n\n Figure 2\n\nThe MCM (2070.2) requires carriers to obtain listings from boards for some provider types.\nFor example, carriers are required to \xe2\x80\x9csecure from the State licensing agency a current\nlisting of psychologists holding the required credentials.\xe2\x80\x9d We found several carriers not\nmaintaining such a listing. They either contact the board for verification, accept a copy of\nthe license from the provider, or do not validate the license. Further, the MCM does not\nspecify how often the listing must be updated.\n\n0 Many carriers allow reassignmentof benefits without determining if the reassignment\n meets Medicare legal requirements.\n\nCarriers are limited by Medicare law in paying assignedbenefits. Payment is made only to\nthe physician or other supplier who furnished the service and may not be made to any other\nperson or organization under a reassignment, or power of attorney, or under any other\narrangement where the other person or organization receives the payment directly. Payment\nis considered to be made directly to an ineligible person or organization if the person or\norganization can convert the payment to its own use and control without the payment first\npassing through the control of the physician or other supplier or a party eligible to receive\nthe payment under reassignment exceptions.3 (See Figure 3.)\n\n\n\n\n 11\n\x0c Reassignment Exceptions\n\n 1) \t Payment to Employer - The Medicare program may pay the employer of the\n physician or other supplier if the physician or other supplier is required, as a\n condition of his employment, to turn over to his employer the fees for this\n services.\n\n 2) \t Payment to Facility - The Medicare program may pay the facility in which the\n service was furnished if there is a contractual arrangement between the facility\n and the physician or other supplier under which the facility bills for the\n physician\xe2\x80\x99s or other supplier\xe2\x80\x99s service.\n\n 3) \t Payment to Organized Health Care Delivery System - The Medicare program\n may pay an organized health care delivery system if there is a contractual\n arrangement between the organization and the physician or other supplier\n under which the organization bills for the physician or other supplier\xe2\x80\x99s services.\n\n 4) \t Payment to a Governmental Agency - Medicare law does not preclude\n reassignment to a governmental agency or entity which qualifies for payment\n under 1, 2 or 3 above as an employer, facility, or organization.\n\n 5) \t Payment Pursuant to a Court Order - Payment may be made provided the\n conditions set forth in the Medicare Carriers Manual, Part II, 5304 are satisfied.\n\n 6) \t Payment to an Agent - The Medicare program may make payment in the name\n of the provider to an agent who furnishes billing or collection services for a\n provider or entity authorized to receive payment.\n\n Figure 3\n\n\nAlthough reassignment exceptions should be testedprior to the assignment of a provider\nnumber, many of the carrier application forms reviewed do not question the provider\nconcerning which reassignment exceptions are met. Only 15 carrier application forms\nattempt to test the reassignment exception. For example, Texas Blue Cross and Blue Shield\nrequests the applicant to specify if an employee-employer relationship exists. (A W-2 would\nindicate such a relationship, whereas a 1099 indicates a contractor relationship.)\n\nAdditionally, 11 carrier group/clinic application forms involving reassignment do not provide\na signed acknowledgement of reassignmentby group or clinic members.\n\nWeak ptvvider number assi@tmentpmcedum contribute to pmgmm vdnembilities.\n\n0\t Carrier methods or practices to identify all provider numbers assigned to a provider\n are inadequate.\n\nCarrier controls to identify all provider numbers assigned to the same entity are insufficient.\nMost carriers make little effort to link related provider numbers. Only five carriers link\nrelated provider numbers with a computer linking tag and only sevenother carriers link\nprovider numbers through their process of building off of a base number (modifiers added to\n\n 12\n\x0cbase number). These linking procedures make determination of a provider\xe2\x80\x99s numbers a\nrelatively simple matter in most cases. However, in order for the linking process to be\ncomplete, the carrier must determine all provider numbers related to a provider at the time of\nprovider number assignment.\n\nOther carriers rely on manual and/or computer searching for related provider numbers for\nthe same provider. Searching may be done by name, SSN or EIN, license number,\nownership, UPIN, or address(or a combination of these). However, carriers typically do\nnot employ all available searchcriteria to identify related provider numbers. Such limited\nsearchesallow for the possibility of missing a related provider number. For example, a\nname search on a businessmight not identify a supplier with several provider numbers under\ndiffering names (e.g., Allied Medical Supply, AMS, Allied Supply). Additionally, although\nthe provider number department may routinely conduct adequatesearchesfor provider\nnumbers, other carrier departments (e.g., overpayment recovery, medical review) may not.\n\nRequesting on the application all additional provider numbers the provider number applicant\nnow has or has had with w carrier is a good practice. Many (24) carriers reported\nrequiring providers to identify any other provider numbers issued by their carrier. However,\nonly 12 carriers report asking for any numbers providers have with other carriers.\n\nThere was no indication in provider files reviewed of searchesfor additional provider\nnumbers. Consequently, we have no documentation of the extent of review effort employed\nby carriers. We do lmow, from talking to carrier personnel, at least one carrier makes no\neffort to check for additional provider numbers, relying solely on the provider to list on the\napplication any existing provider numbers.\n\n0 Providers can manipulate multiple provider numbers and jurisdiction rules to increase\n reimbursement or avoid detection of abusive practices.\n\nMedicare utilizes a system of provider payment based on historical fee patterns and carriers\xe2\x80\x99\ndiscretionary definitions of geographic pay localities, provider specialty, and other payment\nvariables. This process results in payment differentials among types of procedures, carrier\npricing localities, specialties, and sites of care. Additionally, differences exist in carrier UR\npolicies. Combined, these factors create an environment where incentives exist for providers\nto misrepresent themselvesor take advantageof regulatory or carrier loopholes in order to\nmaximize reimbursement or avoid detection of abusive practices. Two areas especially\nvulnerable to abuse are manipulation of provider numbers to avoid program integrity review\nand manipulation of claim jurisdiction rules.\n\nProviders with multinle Drovider numbers can weaken a carrier\xe2\x80\x99s oroaram inter&v activities.\n\nMany of the program integrity staff interviewed report usageof multiple provider numbers\nmake medical and utilization reviews (MRKJR) more difficult. A provider with multiple\nprovider numbers can knowingly or unknowingly, evade some utilization screens(e.g., initial\noffice visits) and possible prepayment or postpayment reviews if all of the provider\xe2\x80\x99s\nnumbers are not identified for review and used in the review process.\n\n\n 13\n\x0cOne of the primary purposes of postpayment UR is to compare the pattern of practice of\nindividual providers with that of their peers in several separatecategories of services, such as\noffice and hospital visits. This review involves the computer generation of the previous\ncalendar year\xe2\x80\x99s paid claims data for all providers in the carrier\xe2\x80\x99s service area. Since the\nprofiles make comparisons to other like providers and predefine4 limits, the failure of the\ncarrier to assemblea provider\xe2\x80\x99s fulI service history through its computer could produce\nmisleading results. Specifically, the UR report may not reveal an existing aberrant practice.\nFor example, a provider with several provider numbers may spreadbillings among the\nprovider numbers so that any one provider number will not exceed a UR screen threshold;\nyet, when combined, may exceed the threshold.\n\nComplicating the adequacyof program integrity activity as well as provider number\nassignment may be a lack of knowledge of each department\xe2\x80\x99s concerns and activities. Only\nfour carrier program integrity respondentsstatedthey were more than somewhat familiar\nwith assignmentprocedures. Additionally, nearly all program integrity respondentsstated\nmore information should be obtained from providers. However, provider assignment\ndepartments may not be informed of or respond to suggestionsby program integrity staff.\nAs one program integrity respondent stated, \xe2\x80\x9cthey rarely utilize our suggestionsfor change.\xe2\x80\x9d\n\nA lack of communication and coordination may lesson the effectivenessof both program\nintegrity functions and the adequacyof provider number assignment. Since each area may\nencounter different problems where improvements in the assignmentprocesscould alleviate,\nboth should maintain close ties. Additionally, this should apply to other areasaffected by\nprovider number assignmentpolicies (e.g., overpayment recovery).\n\nCarrier nrovider number aonlication inadeouaciesand weak euidelines allow manipulation\nand abuse of carrier claim iurisdiction,\n\nCarrier claim jurisdiction issues, addressedin the MCM section 3100, apply to 1) a carrier\xe2\x80\x99s\ndetermination whether this or another carrier is responsible for processing the provider\xe2\x80\x99s\nclaims and 2) what pricing locality within the carrier should be used. (See Appendix D for a\nsimplified view of jurisdiction rules.)\n\nMany carrier provider number applications do not ask sufficient questions to fully test\njurisdiction rules. As an example, only 12 carriers determine through their application forms\nif durable medical equipment suppliers have salesrepresentativesin the State. This is just\none of many questions which could help a carrier determine proper claim jurisdiction.\nFailure to ask such questions could causethe carrier to make an incorrect claim jurisdiction\ndecision which, in turn, could result in payments from carriers with higher reimbursement\nallowances or less stringent UR policies.\n\nCarriers indicate concern some providers (e.g., DME) misrepresent themselveswhen\nobtaining provider numbers or manipulate the jurisdiction rules (e.g., point of sale through\nuse of l-800 numbers or call forwarding) in order to game the system. Specifically, some\nproviders \xe2\x80\x9cforum shop\xe2\x80\x9d to find the carrier paying the most for specific procedures or\nsupplies and/or has the most lenient utilization review policy. Several casesof manipulation\nor abuse have been documented by carriers and 01 investigators.\n\n 14\n\x0c Manipulation of Jurisdiction Rules\n\n Use of l-800 numbers typically involves a company in one state establishing a\n l-800 number in another State for the sole purpose of obtaining a higher\n reimbursement from the other carrier and/or avoiding UR limits. For example, an\n Oklahoma supplier providing supplies to Oklahoma residents may find that California\n has a higher reimbursement rate per item. To get around the jurisdiction rules which\n state that the carrier for the jurisdiction where the order was taken is responsible for\n processing the claim (point of sale), the provider gets a l-800 number in California.\n Instead of making a call to the Oklahoma supplier using a local number, beneficiaries\n are directed to use the l-800 number. Since the point of sale is now California, the\n California carrier makes payment.\n\n\n\nAn example of DME jurisdiction abuseunderscoresa lack of carrier controls regarding\na claim jurisdiction determination:\n\n\n Jurisdiction Abuse: A Case Example\n\n This case involves Medicare Carrier A. Carrier A did not recognize through its\n application process, that a company (Company A) seeking a number was essentially\n a billing entity and not a supplier. Company A had entered into a business\n arrangement with an ostomy supply company (Company 8) operating in another\n state and carrier\xe2\x80\x99s jurisdiction. Company A agreed to buy all invoices for supplies\n sold and delivered from or at Company B. Company A pays Company B 125% of\n the face value of the retail price on the invoice. Company A then bills Carrier A for\n the supplies as if they had supplied them in the first place. Also, Company A is\n alleged to be fragmenting purchased supplies in order to maximize reimbursement.\n Both companies are now under investigation by the OIG.\n\n The carrier\xe2\x80\x99s application process did not identify whether Company A was actually a\n supplier. Had the carrier scrutinized the company to a greater degree, the intentions\n of the supplier might have been discovered during the application process, rather\n than after significant overpayments had occurred.\n\n\n\nCorrect determination of claim jurisdiction may also be an issue with physicians. For\nexample, the definition of a physician\xe2\x80\x99s office for purposes of determining the correct locality\nprevailing charge is vague when the physician provides services in multiple pricing localities\nwith no clearly defined offices or an office which is primarily just a billing office.\n\n Claim jurisdiction can be confusing and could be manipulated by providers unless carriers\n carefully scrutinize provider applications to determine the applicant\xe2\x80\x99s situation. Yet, most\n carrier applications do not request sufficient information from providers to test for unusual\njurisdictional situations. Consequently, it is possible a carrier would not recognize an\n unusual situation and make an incorrect jurisdiction decision resulting in overpayments.\n\n\n\n 15\n\x0c 0\t Most carriers do not uniquely identify physician assistantsand thus, cannot perform\n adequateutilization reviews.\n\nOnly five carriers assign provider numbers to PAS. Those not assigning PAS a unique\nidentifier number do not have a meansof conducting utilization review. Although carriers\nare required to develop charge profiles for PAS, PAS are not subject to the same UR\nmonitoring activity on an individual basis except for a tangential review under the employing\ngroup or physician.\n\nWhile relatively small, the number of PAS has increased the last few years at a rate of over\n2,000 per year nationally. As of the beginning of this year, there were approximately\n23,500 PAS.\n\nDependenceon the supervising physician - PA relationship, the small number of PAS, and\nthe requirement that PA servicesbe billed by the physician may explain why many carriers\nhave devised provider number assignment schemeswhich do not recognize the PA\nindependently (PA given a separateprovider number). Although many carriers do require or\nverify a PA\xe2\x80\x99s certification or license, 11 carriers do not. (See Appendix E for a description\nof some carrier methods for processing PA claims.)\n\nWhile some carriers do not validate the credentials of a PA, several more do not determine if\nthe physician billing the Medicare service is in fact the supervising physician pursuant to\nState registration requirements. An example of such registration requirements exist in Ohio.\nAn Ohio PA is only allowed to practice as an employee and under the direction of a\nsupervising physician or group of physicians. Further, PAS must be registered with the\napplicable State board. Section 4730.02(f) of the Ohio Revised Code states, \xe2\x80\x9cwhen the\nassistantceasesto be employed by the physician or physicians to whom his certifkate of\nregistration is issued, his registration is immediately suspended.\xe2\x80\x9d\n\n0 Carrier computer records maintained on providers need improvement.\n\nEspecially in the caseof computer matcheswith State medical boards to determine legal\nauthorization to practice, certain carrier records must be entered accurately. Two fields are\nespecially important - provider name and license number.\n\nProvider name irregularities exist.\n\nReview of carrier provider files at the three carriers visited revealed carriers enter the name\nas given by the provider on the application. For example, one provider might be listed as\nRobert Stanley Smith Jr. on his license, while the carrier might have entered the name as\nRob Smith or R. Smith on the carrier\xe2\x80\x99s file. Additionally, we saw many providers with\nmultiple provider numbers having different name variations for the same provider.\n\nAnother problem, noted by the Physician Registry, involves hyphenated names. Some\ncarriers have entered hyphenated names in their computer system in a manner complicating\n\n\n\n 16\n\x0c matching with the Registry. As an example, a carrier might submit records having \n\n hyphenated names where the fust part of the hyphenated name is in the last name field while \n\n the rest of the name is in the suffix field. This makes computer matching of the name fields \n\n very difficult according to the Registry. \n\n\n The situations mentioned above create unwarranted confusion not only for computer matching \n\n but for anyone reviewing provider records. \n\n\n Provider license numbers are missing or inaccuratelv entered, \n\n\n License numbers facilitate communication with licensing agenciesconcerning providers who \n\n have lost the legal authority to practice. Specifically, it is a crucial data element for \n\n computer or manual matching which might occur with data supplied by a State licensing \n\n agency or board. \n\n\nWhile few carriers do not record provider license numbers in the provider\xe2\x80\x99s computer \n\nrecord, a considerable number of carriers have only recently begun this activity. \n\nAdditionally, several carriers do not enter the license number for all types of providers. For \n\nexample, 13 carriers do not enter the license number of an independent clinical psychologist. \n\nThis compares to only two carriers not entering the license number of a doctor of medicine. \n\n\nEven if the license number is entered, carriers may not be ensuring the accuracy of the \n\nnumber. To illustrate, in the three carrier provider Nes reviewed, we encountered error and \n\ninconsistency in the recording of license numbers. Transposing digits of the number was the \n\nmost frequently encountered error. To a lesser extent, some license numbers were \n\nincomplete, had too many digits, or included inappropriate prefixes. \n\n\nMany caniers assign adZtional provider numbers solely for a ptwider\xe2\x80\x99s bookkeeping \n\nconvenience. \n\n\nSeveral situations can allow a provider to legitimately have more than one provider number \n\n(or modifier to a base number). Carriers give a physician who practices in both a group and \n\na solo practice a number for each. If a provider has a practice in more than one reasonable \n\ncharge locality, carriers assign the provider different provider numbers or modifiers to an \n\nexisting provider number for each of these localities. \n\n\nHowever, a solo provider with the same specialty and practice in the same pay locality can \n\nhave only one customary charge profile regardless of the number of offices maintained \n\n@KM 5209). Some carriers interpret this to mean the solo provider may have only one \n\nprovider number per pricing locality. To give the provider more provider numbers would \n\nperform only a bookkeeping purpose for the provider since payment would be the same if an \n\nadditional provider number were given. \n\n\nOn the other hand, some carriers appear to have fewer limits on the number of provider \n\nnumbers or modifiers given to a provider. For example, a physician with multiple office \n\n\n\n\n 17\n\x0csettings in the samepricing locality could be given an additional provider number or a new\nmodifier to a base number for each unique address. Also, if the payee or tax identification\nnumber under which payments are recorded is different, the carrier assignsdifferent provider\nnumbers.\n\nAs one carrier medical director stated, \xe2\x80\x9cit appearswe are being asked to act as a bookkeeper\nby providing multiple provider numbers.\xe2\x80\x9d One example cited by the director involves\nmultiple provider numbers assignedto a radiologist \xe2\x80\x9cin order to segregatepayments for his\nprofessional servicesas opposed to payments to the sameradiologist for technical services\nwhere the equipment may be owned by a different entity.\xe2\x80\x9d Several carriers reported that\ngiving multiple provider numbers was just a \xe2\x80\x9cmatter of courtesy to the provider. * One\ncarrier cited specific direction from its accounting department to \xe2\x80\x9cgive multiple provider\nnumbers for eachphysician practice location.\xe2\x80\x9d\n\nFigure 4 depicts the different carrier practices in assigning additional provider numbers (or\nmodifiers to a base number) to the sameprovider. It also shows some carriers treat certain\ntypes of providers differently when assigning additional provider numbers for the\nbookkeeping purposesof the provider.\n\n Many Carriers Give Additional Nunbers for\n the Provider\xe2\x80\x99s Bookkeephg Convenience\n Carriers\n 1A\n\n\n\n\n DME Ambulance\n\n Source: Carrler Survey (23 rerpondentr)\n\n\n Figure 4\n\n\n\nData supplied HCFA by the Physician Registry confirms many physicians do have more than\none provider number. (See Figure 5.) Over fifty percent of medical physicians (doctors of\nmedicine or osteopathy) have multiple carrier records at the same or other carriers. The\nHCFA refers to such records as active practice settings.\n\n\n\n\n 18\n\x0c Many Medical Physicians Have Multiple Provider Numbers\n with the Same or Multiple Carriers\n\n Carrier\n rlumbers/ Four or More\n Records One Carrier Two Carriers Three Carriers Carriers Total\n 1 187,618 46.3% 0 0.0% 0 0.0% 0 0.00% 197,616 46.3%\n 2 92,651 21.7% 28,738 6.7% 0 0.0% 0 0.00% 121,380 28.5%\n 3 36,561 8.6% 16,600 3.9% 1,331 0.3% 0 0.00% 54,692 12.8%\n 4 15,405 3.6% 8,483 2.0% 1,083 0.3% 75 0.02% 25,056 5.9%\n 5 7,246 1.7% 4,338 1.O% 631 0.1% 79 0.02% 12,286 2.9%\n 6-10 7,966 1.9% 5,028 1.2% 804 0.2% 145 0.03% 13,943 3.3%\n Ii-46 786 0.2% 581 0.1% 82 0.0% 33 0.01% 1,504 0.4%\n Total 358.237 84.0% 63,979 15.0% 3.851 0.8% 332 0.08% 426.499 100.0%\n source: Preliminary UPIN data presented by HCFA researchers at the 118th Annul Meeting of the\n American Public Health Association, October I, 1990.\n\n Figure 5\n\nVariation exists from carrier to carrier concerning the average number of active records\n(practice settings) for physicians with UPINs. Carrier averagesrange from a low of 1.05 to\nas many as 2.49 provider numbers (practice settings) per physician. (See Appendix F.)\nWhile many factors such as the number of carrier pricing localities or local physician\npractice patterns may help to explain carrier variations, carrier easeof assigning multiple\nprovider numbers is surely a significant factor.\n\nInterestingly, we found three carriers with multi-state jurisdiction, and the States\xe2\x80\x99 averages\nwere vktually identical. (See Figure 6.) This finding underscoresthe impact a carrier\xe2\x80\x99s\nprovider number assignment policy can have on the average number of provider numbers per\nphysician.\n\n Carrier Policy Impacts Provider Numbers (Records)\n .:. ~.\xe2\x80\x98..\xe2\x80\x98.\xe2\x80\x9c..\n .\xe2\x80\x99.f??I::::::J:\n :.:::.- .:-.:... .:.:.::.::: . J Uris& ction\n ::. : :\n \xe2\x80\x9d\n ,. ;,.\n .\n ., !..: 1: :\xe2\x80\x98?\xe2\x80\x98I:::I~:]j\xe2\x80\x99l:~:/~~:~f<:.\xc2\xad..-&\xe2\x80\x98fii&\n :. :. ::. \xe2\x80\x98.\xe2\x80\x99\n ,~;::::~:fi~\xe2\x80\x9d :I:: ~:.~~:~:::~:~,:::j\n : :. .,.\n Avg. Xdrocords\n \xe2\x80\x98. .. per Physician\n\n Nationwide Mutual Insurance Ohio 2.20\n West Virginia 2.35\n\n Aetna Life and Casualty Oklahoma 1.32\n New Mexico 1.32\n\n Blue Cross and Blue Shield of Arkansas \t Arkansas 2.14\n Louisiana 2.14\n\n\n Figure 6\n\n\n\n\n 19\n\x0c RECOMMENDATIONS\n\nThe HCFA should:\n\n0\t specify a minimum framework for provider number assignment to be followed by all\n carriers. Within this framework carriers should be allowed flexibility for\n implementation. Additionally, this framework should recognize similarities and\n distinctions between types of providers. Some areas to addressinclude:\n\n the minimum essential data elements carriers are to maintain in their computer\n systemson providers,\n\n other information deemed necessaryor valuable for the carrier to obtain from\n providers during the provider number application process,\n\n provider information to be validated and the method(s) of verification, and\n\n carrier responsibility to:\n\n b\t maintain a list of all Part B provider types with corresponding Federal,\n State and local laws affecting legal authority to practice and the\n carrier\xe2\x80\x99s methods of verifying legal authority. Carriers should be\n required to maintain communication with appropriate agencies (e.g,\n licensing) adequateto understandand monitor changesin legal\n authorization requirements.\n\n b\t ensure, before issuing a provider number, adequatedocumentation on\n each provider number assignmentincluding:\n\n 1) \t a completed application (containing a penalty clause for making\n false statements)signed by the individual provider; the owner, if\n a business; or a company official, if a corporation,\n 2) \t the method and contacts used to verify the provider\xe2\x80\x99s\n credentials,\n 3) \t a list of all other provider numbers assigned the provider (the\n carrier should determine the need for continued use of identified\n numbers and document justification for the new number), and\n 4) \t the specific reassignmentexception(s) applicable as well as a\n statement, signed by the reassigning provider, acknowledging\n the reassignment.\n\n\n\n\n 20\n\x0c b\t query the Registry, prior to assigning a provider number, for all active\n records/practice settings listed for the specified physician. The carrier\n should ascertain a provider\xe2\x80\x99s need for identified provider numbers and\n deactivate those not neededin their jurisdiction. The carrier should\n notify other carriers where numbers exist. Also, if an existing number\n is flagged for any type of carrier review, the new provider number\n should be considered for possible review as well.\n\n b\t maintain relevant application documentation (e.g., application form) for\n active provider numbers.\n\n b verify provider qualifications.\n\n b\t have adequatesystem controls to 1) identify all provider numbers\n assignedto a particular provider and 2) ensure providers with multiple\n provider numbers cannot avoid prepayment review or screens,\n postpayment utilization review, and overpayment recovery.\n\n b\t identify all providers (e.g., physician assistants)adequatefor\n utilization review on an individual basis.\n\n b update (at least) annually any listings used for license verification.\n\n b\t identify the ownership of providers and maintain such information in\n the carrier\xe2\x80\x99s computer system in a manner ensuring identification of\n entities having the same owners. Carriers should review the ownership\n databasefor sanctionedindividuals or entities.\n\n b\t maintain provider records which are complete (e.g., license number\n entered in file) and consistent (e.g., name field should carry the same\n spelling in each record pertaining to the provider).\n\n b\t evaluate their provider application forms to ensure they are well\n designed, easy to understand, and professional in appearance.\n\n b\t ensure coordination between the provider number assignment staff and\n other departments (specifically, those for program integrity - medical\n and utilization review) for the sharing of experiences and suggestions\n for improvements to provider number assignment procedures.\n\n0\t consider implementation of a system of user fees to defray the costs of provider\n number assignment and maintenance (e.g., determination of legal authorization to\n practice, Physician Registry contact for prior or present practices, more extensive\n review of applicants, assignment of additional provider numbers for a provider\xe2\x80\x99s\n convenience, and efforts to update records).\n\n\n\n 21\n\x0c0\t expand the Physician Registry to include non-physician practitioners such as clinical\n psychologists, audiologists, nurse anesthetists,midwives, physical and occupational\n therapists, nurse practitioners, physician assistants,and clinical social workers.\n\n0\t require the Physician Registry to provide feedback to carriers concerning all active\n practice records (settings) for physicians with unique practitioner identifier numbers.\n\n0\t ensure carrier implementation of HCFA provider number assignment directives. We\n recommend HCFA consider evaluating implementation through a Contractor\n Performance Evaluation Program (CPEP) standard(s).\n\n\n\n HCFARESPONSEAND ACTION PLAN\nThe HCFA provided written comments on the draft report. More importantly, however, \n\nHCFA itself has undertaken several major initiatives to addressthese problems and related \n\nissuesraised in a prior OIG report entitled \xe2\x80\x9cCarrier Maintenance of Medicare Provider \n\nNumbers. \xe2\x80\x9d We and HCFA, therefore, worked together to reach agreement on an action plan \n\nto improve the provider number process. In light of this, we are no longer designating the \n\nproblems cited in this and the prior report as a material weakness. The following is the ~\n\nagreed upon action plan: \n\n\n\n MEDICARE PROVIDER NUMBERS\n\n ACTION PLAN\n\n GEh?ERAL\n\n HCFA will issuea modification to the Medicare Carrier Manual which will:\n\n Clearly statethat carriers have a responsibility to ensurethe integrity of\n provider numbersandto ensurethat only thosepractitioners andproviders\n with legal authority to practice are given and may retain provider\n numbers.\n .\n Require carriersto stayabreastof changesin relevant laws and regulations\n concerningmedical practice requirements.\n\n Require carriers to make every reasonableeffort to receiveon an ongoing\n basis information from State licensing authorities and other appropriate\n bodies about the currency of licenses.\n\n Require carriers to maintain provider number applications for at least six\n years after deactivation of the number (the period needed to facilitate\n\n 22\n\x0c investigations, prosecutions, and sanctions). This requirement pertains to\n applications from both health professionals and provider entities which are\n discussed separately below.\n\n Require carriers to periodically purge from their lists of approved numbers\n those that have been inactive and for professionals or entities who no\n longer have valid licenses required by the State.\n\n\nEEALlTl PROlTESSIONALS\n\nHCFA will continue to vigorously implement and enforce compliance with the\nprovisions of the recently established UPIN system for Medicare physicians\n(which includes medical doctors, osteopaths, dentists, chiropractors, podiatrists,\nand optometrists).\n\nHCFA will explore the extension of the UPIN system to cover all limited licensed\nprofessionals that can bill Medicare directly. HCFA will provide a schedule for\ndoing so. This would include clinical psychologists, clinical social workers, and\ncertified registered nurse anesthetists.\n\nAll registry data will be made readily available to all carriers on January 1. 1992.\n(Procedures prior to that date only allowed carriers to obtain information about\nprofessionals within their own jurisdiction.)\n\nHCFA will monitor and ensure compliance of the carriers with their responsibili\xc2\xad\nties regarding provider numbers as set forth in the Medicare Carrier Manual. (See\nGENERAL section above.)\n\n\nSUPPLIERS\n\nHCFA will implement a major reform of the carrier process for dealing with\ncertain \xe2\x80\x9csuppliers\xe2\x80\x9d. (Here, the term is meant to include entities which provide:\ndurable medical equipment, routine and readily available supplies, prosthetics,\northotics, immunosuppressant drugs, and ESRD services.)\n\nSome of the more important features of this initiative are:\n\n Four regional carriers will be responsible for establishing supplier numbers\n and processing all Medicare claims for the above mentioned supplies.\n\n A clearinghouse which will contain information from supplier number\n applications and whose data will be accessible to all of these carriers.\n\n A standard application form which includes information to enable the\n carriers to identify each unique entity, their ownership, related entities,\n and sanctions.\n\n\n 23\n\x0c The application form will contain a signed statement of the applicant\n attesting to the veracity of all information provided and acknowledging\n responsibility for false or misleading statements.\n\n The carriers will be responsible for processing all claims for supplies\n furnished to beneficiaries who reside within their jurisdiction.\n\nHCFA plans to implement this major reform within the next two years.\n\nThe statement of work for the contract under which these carriers will function\nwill include a clear statement of responsibilities concerning supplier numbers\nsimilar to those listed in the GENERAL,section above.\n\nThese carriers will be required to use the information in the clearinghouse to\nscreen applicants for supplier numbers for such things as relationships to\nsanctioned individuals or business or to businesses suspected of fraud or abuse.\n\nThe carriers will verify the accuracy and completeness of the information\ncontained in supplier number applications and files, and will identify and take\nappropriate action against problem suppliers.\n\nHCFA will vigorously monitor compliance of these carriers with those contractual\nprovisions related to the application for, granting of, and maintenance of supplier\nnumbers. HCFA is determining how the performance of these carriers will be\nevaluated.\n\nHCFA will require carriers to reenroll all suppliers every two years to insure that\nthe ownership and operating information remains current.\n\nIn the future, HCFA will extend this system to cover other supplier entities such\nas independent physiological labs, magnetic resonance imagers, and ambulance\ncompanies. In the meantime, however, these other supplier entities will be\nrequired to use a standard application form with provisions for identifying\nownership and sanctions, and including the signed veracity certification.\n\n\n\n\n 24\n\x0c Endnotes\n\n1\n Only a few statesmonitor medical suppliers. One state, North Carolina, requires places\n dispensing prescription devices (e.g., TENS units, support hose, catheters) to register\n with the State Board of Pharmacy. An application must be completed before a permit is\n issued. The person issued the permit must supply such information as his education,\n home address, social security number, criminal history, employment history, and photo.\n New York is pursuing legislation to provide similar authority to its pharmacy board.\n Although the Board assignspermits, the Medicare carrier for North Carolina does not\n verify a supplier\xe2\x80\x99s permit prior to assigning provider numbers.\n\n Another state, California, has passedlegislation giving the Department of Health\n Services (Medi-Cal Prograrh) the authority to require more involved information from\n suppliers of incontinent supplies (e.g., diapers). For example, suppliers must have a\n retail businesslocation (not a P.O. Box) and,inventory. Additionally, operators are\n required to supply such information as owners, interested parties and the driver\xe2\x80\x99s license\n numbers for names reported. Suppliers misrepresenting themselves through either the\n application or supporting documentation are subject to criminal penalties of up to 5 years\n in jail and as much as a $500,000 fine. A State official reports efforts to have the law\n amended to apply to other types of suppliers (e.g., durable medical equipment).\n\n2\n Suppliers such as DME often provide oxygen and other medical gasesto beneficiaries.\nIf the supplier repacks (transfills) the gases, they are required to register with the Food\nand Drug Administration (FDA). FDA conducts annual inspections of registered\nsuppliers. Although it is a criminal offense not to register, FDA has not sought\nprosecution. Suppliers who do not register are not inspected and therefore, are not\nrequired to correct violations of FDA regulations nor stopped from providing gasesif a\ndanger to the public exists. None of the carriers contacted require FDA registration\ncertificates from suppliers. In fact, no carrier\xe2\x80\x99s application form even asks the supplier\nwhether they repack gases.\n\n3\n A new reassignment exception has been recently added. The exception allows\n physicians covering the practice of another physician to reassign payment to the absent\n physician for a specified period of time.\n\x0c APPENDICES \n\n\n\nAppendix A: Part B Providers\nAppendix B: Carrier Respondents and State Jurisdictions\nAppendix C: Examples of Information Requested on Application Forms for\n DME and Physicians\nAppendix D: Claim Jurisdiction Rules Simplified\nAppendix E: Examples of Carrier Methods of Processing PA Claims\nAppendix F: Physician Registry Activity by Carrier\nAppendix G: Carrier Provider Number Assignment Activity\nAppendix H: Carrier Supplied Counts of Various Types of Providers\nAppendix I: HCFA Comments to the Draft Report\n\x0c APPENDIX 6\n\n\nPart B Providers\n\x0c APPENDIX I$ \n\n\n\n\n\n * l\n Blue Cross and Blue Shield of Alabama AL \n Alabama\n * * Aetna Life and Casualty AZ, NV \n Arizona, Nevada\n * * Arkansas Blue Cross and Blue Shield, Inc. AR,LA \n Arkansas, Louisiana\n *\t * Blue Shield of California CA \n California\n * Transamerica Occidental Life Insurance CA \n California\n Blue Cross and Blue Shield of Colorado co \n Colorado\n * Travelers Insurance CT \n Connecticut\n * Blue Cross and Blue Shield of Florida, Inc. FL \n Florida\nI * * 1Aetna Life and Casualty IGA \n 1Georgia\n * * Aetna Life! and Casualty 1HI \n 1Hawaii\n * * Equicor 1ID \n 1Idaho\n * * Health Care Service Corporation I IL \n I Illinois\n * Associate d Insurance IN \n Indiana\n l\n Blue Shield of Iowa IA \n Iowa\n * Blue Cross and Blue Shield of Kansas KS \n Kansas\n * Blue Cross and Blue Shield of Kentucky IKY \n 1Kentucky\n * Blue Cross and Blue Shield of Marvland 1MD \n 1Marvland\nI * I * 1Blue Cross and Blue Shield of Massachusetts 1\tMA, ME 1Massachusetts, Maine,\n VT,NH Vermont, New Hampshire\n * * Blue Cross and Blue Shield of Michigan Ml Michigan\n * * General American Life MO Missouri\n * l\n Blue Cross and Blue Shield of Kansas City MO,KS Missouri, Kansas (Johnson and\n\n\n\n\nI\n** Blue Cross and Blue Shield of North Dakota has assumed responsibility for Wyoming from Equicor.\n\x0c APPENDIX 6\n\n\n Information Requested on Application Forms for DME\n ,.....:\n.\xe2\x80\x98:.........:.,:\n . ,,.:.,:\n ;:...\n ..>::.>:.:.:.:.:.::::.:.:.-.\xe2\x80\x99\n ,:.:-.-:\n .:::i::i:i:\xe2\x80\x98!::i,::li:;\n j:j:j:j:. ..,.,.\n ;..:..:::.::, :,.,.\n :::\n .:.::::::::.:.\n \xe2\x80\x9c.....\xe2\x80\x98.....\xe2\x80\x98.\xe2\x80\x98.hi,.\n ..: ..,.,......,.,. ..:..:.::j.:\xe2\x80\x98:\xe2\x80\x98..:..\n ......).:,.):.,.:.:::\xe2\x80\x9d\n .:. .\xe2\x80\x98::::::....:\n ..):.))),.:.,\n ,.,...,....~.\n ....,,\n j.....;::F:y,,::..\n :::::)::,:i:::.j:.::j:i ..i..11/../\n .i.... ..::::\n ..:.::.\n : /,...:.:::::.\n ../.\xe2\x80\x9d\xe2\x80\x98: .:.:.:.:.:::... ,.j::j:::::::.:jj:jjj:j::ky.,\n ..::..::.::\n ....:jjjjj:.:.:. .:Kj:j:j:.::.,.\xe2\x80\x991..<:j:.:.::.:\n :...::.\n ..::::j.j:j.:.::.:.:.:,:.:.:..:\n :.:\n ..)). :..:\n :.::j,:,::,...\n ::::\n ..:: :..:::.:\n .::. : :.:.,:I,::.,\n y..,..\xe2\x80\x9c\xe2\x80\x98:..::\n .:.:.:.: .c&e& \xe2\x80\x98.&&G&&bata\n .:.\n ... .......\n . . \xe2\x80\x98?,\n . :,,,.,.\n j ;\n : :/:;\n ,::..:::.,,\n ,::::.:\n ,.. .\n ..,..\n\xe2\x80\x98ii~~i;ilil:iiiiiii;~~~~~~~~~~~~~~~~~~~~~~~~~:~~~:~:~:.. :.::3:,\n ,.:.::.:.:.:::.y ::::::::::::.\n :::.x...\n :.:.. :.:: . :... .\n :\xe2\x80\x98:.:i\xe2\x80\x99;,:,\n .:::::::\n :::::\n ..,.,.\n .,.,.,.\n : .......\n.,.,.,..))~,~, . ..... .,.,.,.,.,.,. ,:,c.;:\n ,..,.,.,.,\n .;,.,_.,.\n ..,.,.,.,\n .,., ,....\n :,:,::,lfi~~~~mq@&\n :\n .,., :,jc:j;i:i;i;ji.;:j\n ....:...::.,.\n . ..: .:.. ....::..$$$ j;:::::;:;i.:\n . ;.;5:;;:.::?;;I:.:3;::: .,.,:$$$,:::,;;\n z;;...\n .+;;I;w\n Count:,c.Percent\n .,.,., ..7\nBackground/Profile Information:\n:I\xe2\x80\x99;;iji,.:s~~~~~~~~:~~~.:~~~~. ./:j)$:.:;\n ..... . :.jj::ii:.\xe2\x80\x98..ij:::::~j::.I:jIi::.~~\n .I y. ;$:I... .... .Y.\xe2\x80\x98jj:iB.. .:..:.I:\n \xe2\x80\x98.:,y:l.;i;;::i. .,. .:.:: .:::$::I:::, :jji,,x,:j;...1.;;....;. j: \xe2\x80\x98.:.: ::yy I .:. \xe2\x80\x98fj@&\n Doing Business As (D/B/A)\n :iri$$l:\xe2\x80\x98;i;;\n$$,;;;;Bil~ig ~&f&e~, :::ii:llij<,, ....,,;I$;, ,.,;:::l:::;\n $:i;i;;;..;f:.:.\xe2\x80\x98:~~;+.;::;:.:I::\n +i/;/; I:I:,:,I;;:;;;~~:~;~~.\n :.;:;,,;: j;:jjl:l:;l:::~:,,~:~\n :::::;;.::i,;:)li;jii:T:j\n ::i:i;:j ;.&:,:,:I::;:::I::,:1::.;.1,.,;y;. .; :A.:.:I.!.:x\xe2\x80\x99g\n$;jj:il::B&G&&,(,ffi~ ........... ....;.::.:.x,;j\n Bi!iing Te Wme jJ$.J&@,z:~~:i\xe2\x80\x99:\xe2\x80\x98:;y~ ...... .\n ,~y\xe2\x80\x99$\xe2\x80\x98!\xe2\x80\x98:,I:j: .............;;:::~::i::~,\n :.:;;y . ,,.....:;;::?\n \xe2\x80\x98-:::jj:~/\n T\xe2\x80\x99:j;j:;.~$:iji;::i:ij;::,.::I:: .:::.,: \xe2\x80\x9c\xe2\x80\x98..\xe2\x80\x99.\xe2\x80\x9c\xe2\x80\x983$\xe2\x80\x99...:::;;:;\n .:iij\xe2\x80\x98.::,;::::y ; :\xe2\x80\x98:agig\n\n\n\n\nRequest for Some Type of Documentation with Application: \n\n\n\n\n\nCertification and Signature on Application: \n\n\n\n\nType of Business: \n\n\n\n\n\nQuestions Concerning What and How Services are Provided:\n\n\xe2\x80\x98:~:::\xe2\x80\x98l\xe2\x80\x9d(jn~r-~&&~~~~~~s tin mis &g@ :.:. I..: .: :.:.:I)\xe2\x80\x98..\xe2\x80\x98I\n y~b&d@,g~lj&ifi&~~\\~ \xe2\x80\x98. : l... -3% \n\n Does the beneficiary sign contract prior to or at the time of delivery,,, .g\n\xe2\x80\x98:( Does acontract indicate if the supply is rental or putia;sed .: ...::1. \xe2\x80\x98.. : ... .I:j:,:.\xe2\x80\x9d :1\n is the equipment provided both purchased and rental items or purchaseonly \n\n How are prescribin physicians\xe2\x80\x99 and benef~iaries\xe2\x80\x99 si natures obtained :- :z \n\n The names and ad 3 resses of parties supplying your B ME equipment\n\n \xe2\x80\x98>\xe2\x80\x98Do safes representzltlves aiways have direct onsite contact with beneficiary at sale :- 2\n\n Are sales made through catalogs \n (mailorder) 11% \n\n Describe how items are .marketed ;~\n Describe how orders are received and processed (e.g., phone, mail, or in person) 4 1z\n tf testinq is performed, what tape is done and what ohvsician provides trainino 1 3%\nOwnership, Financial Interest, and Employee Questions:\n Owner\xe2\x80\x99s name 22: 59%\n List ail licensed practitioners who are employees, owners or have a financial interest\n list ail licensed ractitioners who are cons&ants or contractors :~ ii;\n Number of emp Povees 1 3%\n\x0c Information Requested on Application Forms for DME (cont.)\n ..( :,). :\xe2\x80\x99 .. : .\xe2\x80\x98. ..:.,.,.j:::::i:::.. . .\n ,: :.,. ..\xe2\x80\x98,\xe2\x80\x98. . ........\xe2\x80\x99..,:.,,:. :: ..:: .. ...:.. :. .\xe2\x80\x98. .:.: ....\n ::. :.:,.s:.. : .,: . ..\xe2\x80\x99 .\xe2\x80\x98. \xe2\x80\x98,,\xe2\x80\x9c. .,.: .:.:..::. .:.. \xe2\x80\x98I\xe2\x80\x99.\n .. . . . ,:..:. \xe2\x80\x98. : ,,,\xe2\x80\x98, .: .\xe2\x80\x99 .::;:I:.:\xe2\x80\x9c:.:\xe2\x80\x9c:\xe2\x80\x98...:.:: ..:,: ,: .,: ,,, .,:: ,:;..:... :\n .. :... .,.,. .... . 1,\n ::::Y?.:..:f...\xe2\x80\x98.\xe2\x80\x98. . :j:.:.... ;:.\xe2\x80\x98.:. ~-I\xe2\x80\x99~f~ation.:Reguested ~~;:;\xe2\x80\x98:;;::: .:::;T. .,... ;?:: .,... .. : ?;.:I .j: :,:..,,, ,.::I:. : w\xe2\x80\x99, ; :; pe&.jt\n ::;::.::.l:.\xe2\x80\x98l~:~\n ..::...:.I: ,.;,;;:,,,?::..,..:::.::) .\xe2\x80\x99 .\xe2\x80\x9c. .: .,\n : .: ..... :: :: ..\n\n Billing ,C+estions:\n ~;:::::;$is-~\xe2\x80\x98~b;li~g\n \xe2\x80\x98e&e u& (pioin& ,:... ..,; .. .\n t&$&me and $jdEs) .. .. : .. ,:., .\xe2\x80\x9c:. ..,\xe2\x80\x9c\xe2\x80\x99 ,, fi .. -1696\n Will this.offie bill by electronic media claims 11%\n ::\xe2\x80\x9c:\xe2\x80\x9ci\xe2\x80\x9d!p*&g#&lbcg;ti;ori .&\xe2\x80\x98~l~ing @Co&-, .ji.:j:;:,. \xe2\x80\x99 : : ;.. .. .. .....:...:I:j:\n :; ,,, .::;.::.:.. . . .I..\n $g\nI ,.\n fs a.hospital your biifing agency 1\n i:.:.%,bg&$& eentra u,rjg :&jje,-,,, %:..,,\n .,: ;. . .. ::\xe2\x80\x99 \xe2\x80\x98: j .... .., , .j... ....:.;g\n Will\n .,. you bill from your corporate or office address 1 3%\n \xe2\x80\x98Am.b&hMediwre and NonMedicampaknts charged the same for the same\xe2\x80\x99st&vices \xe2\x80\x98.\xe2\x80\x98. :j :: :\xe2\x80\x99 :.:;.%%\n Will YOUbe biiiina for patients located in other states 3 8%\n Participation Status Question$;.\n \xe2\x80\x98Y$i& j;ou pmicip~e(jtn\xe2\x80\x99.#&d&&ythe && ... \xe2\x80\x98:,. .;.... y...;.+. :. .; .. .... ,,, .j.... ~g~.\xe2\x80\x98,-:I::~.:y;cr%\n :c.\n Do vou accept assionment (will participate) 2 5%\n Qu,estions to Determine Jurisdiction, Other Provider Numbers, and Service Area.. :\n .,\xe2\x80\x9c:Do~~~\xe2\x80\x9c\xe2\x80\x98~iii:other &a. i+i&r&$com~$jies : .: 1 \xe2\x80\x98.: :3%.\n Do you have other numbers with this carrier 5 14%\n .....Do yo$&&tly have a.Medic& biliihg number in~&&&&s .:,. ,\xe2\x80\x99 ... ,\xe2\x80\x9d 9.\xe2\x80\x98. .::\xe2\x80\x9824%\n .,Do you bill any of these numbers? if so! what items are billed at each 1 3%\n .. \xe2\x80\x9d 2 I~ ::tjtg\n : Do~o~+~~ers~oljeratorshave&y-other numbers\n Qst ail companies related to yours which are or have been Medicare providers 3 a96\n .\xe2\x80\x98Arethere any similar companiesin this State in which\xe2\x80\x9downers have a financial interest 3\xe2\x80\x99 ..a96\n in what States have you been located and what numbers were used 2\n : ., Do j&\xe2\x80\x98hab.&f&i.aeli&j \xe2\x80\x98&f&s/l~aQon$ jn the St&$<.:<.:.:c: .13\xe2\x80\x99: :. 5%\n 35%\n Are you pan of a chain of stores with a centralized billing office 3 a96\n .. \xe2\x80\x98--~I.:if,yes;shwid\xe2\x80\x99corres~de~e be sent to the billing offii ......:: .. .. \xe2\x80\x98. :. ,:.:,. I : :3%\n ..is this company a chain store\n ..\n 1 3%\n : ,, fsyou::cdmp~y .assodi~d ~ \xe2\x80\x98any othe\xe2\x80\x99r\n :a%\n supply cOm:p~~:;l:,~.:, ... \xe2\x80\x9c, 1 :\n\n\n\n\n ff yes, what is the numberof sales outlets, names, .and are charges uniform 1 3%\n W~all.indi\\riduals.~a\\iing.a-financial\xe2\x80\x99inierestin your company\xe2\x80\x99tio have been in Medicare 2 :5%\n Do,you have a branch office in this State 1 3%\n .~::~::l&~&r?&ffi~@:& &&i&f!& ~ain\xe2\x80\x9d~ff@ ,,.,,,,;j j . ::,;,,, .. ..1: 3%\n is,yw firm a branch office or muiti-state supplier? if so, where are billing and tax records 1 3%\n ..\xe2\x80\x98Doywhave saies\xe2\x80\x99represent&es\xe2\x80\x9din this state (gNe names, addresses and phone %s) 12\n What is the name of your parent company 2 5%\n ;Are yw hospital 6-d ;:ji ;, ,:$.; \xe2\x80\x98:: 2~ 5%\n is a member of this entity currently employed by another state or out-of-state company\n in a management, accwnting, auditing, or similar capacity 2 5%\n\n Questions Concerning the Supplier\xe2\x80\x99s Past:\n Datethis business started (or first started providing services) 12 32%\n Have you recently terminated your association with any supply company in this area 1 3%\n Was this company purchased (give business name, previous owner and 1 3%\n were accounts receivable purchased by you) 1 3%\n Have VW had a biiiina number in this area 2 5%\n\x0cSome Types of Information Obtained on Physician Application Forms \n\n\n\n\n\n3lny provider numbers with other carriers\nWill a billing service be used\n\x0c APPENDIX ti\n\n\n Claim Jurisdiction Rules Simplified\n\n\n TYPE SERVlCES JURISDICTION\n DETERMINATION\nPhvsicim Servic88\n S8rvic88 r8nd8d from m office Curiw 88rvicing offic8 loc8tion\n In a 8ingle pay lodii\n\n S8rvic8s r8rd8d from offic88 E8ch offic8 8srviced by 8ppropri8te\n in more thm on8 curid 8re6 cmitn baed on each office location\n\n No office, us- hom8 8ddra8 Home ad&m loc8tim\n\n Servica provid#l by ouGd8 bC8tiOll Of OUt6id8 f8Cikv\n f8cilii (e.g., clinic)\n\n provide fdii bib for Lowtion of provider f8cilii\n 884088 of provide-brd phricim\n or phy8ici8n8 who r8nd8r8 88rvic88\n primurily in provider fdi\n 8etting 18.0.. 886x8 p8rfornd\n in 8 hapitd 88tting, hcepital bill81\n\n\n Provkk-bned phy8icim who m8int8ins 8 Priv8te office location\n priV8t8 Office for th8 tr88tt,I8nt Of\n hi6 OW\xe2\x80\x9d p8ti8tlt8\n\n\n Provider-bad phy8icim bilk Loc8tion of provider f8cilii\n p8tient8 directly or through\n billing 86rvice ~6% doa not\n h8V8 m OffiC8 OUt6id8 the\n provide fdri\n\n Provider-bm8d phy8icim performing Eech providsr f8cilii loaltion for\n 88rvica in mor8 thm on8 ftiri 8ervic86 r8nder6d therein\n\n\n Note: Pnyeiciens who meintain more then one office cennot be nzquired to bill from eech of&e for the services\n renoked h the indduel offie.\n\nSuodier Servic66\n A 8i,,gl8 OffiC8 8Uppli,,r i6 8 8Uppkr with brmdl OffiC86,88k/rmt8k OUtkt6, or r6qX6J68flt8tiV86 in only on8 CMl\xe2\x80\x99i8r\n jurisdiction. Multi@8 ~8rri8r 8Uppk6 8r8 thO88 6uppk6 with brmCh 0fflC66 or 8d88/rmtd outlstr in more thm\n on8 curkr g8ogrphic ~88.\n\n\n single office rupplier \t Cmiw 88rvicing office loation regardl868 of whsthsr\n 8uppkN providm 86rvic86 to cu6tom6~6 out6ide the fxrrier\xe2\x80\x998\n 86rViC8 =88\n\n\n Multiplbcarrier 8upplkr Locetion of where the 88rvics i6 fumi8hd to the beneficiwy\n whsther or not the 8uppk 1186s 8 cmtrd billing office (e.g.,\n the 8ite where the compmy met with ths beneficiary or\n where the compmny received the b8n8fiCiq\xe2\x80\x996 c8il - where\n the 88rvice we6 furrkhed)\n\n\n DME 6upplier with branch offices Location Of Where purchase m8d8 or c8t6h3g 848 or if no\n branch office or c8tdogua outk. ths location Wh8r8 the\n regiond c8tdogue center is located md from which the\n equipment ~166 8hippod\n\n\n SUppli8r Of pOrtti8 X-ray, EKG, Or Location of where the rervice is rendered\n 8i,,Iih,r pOrt8b,8 88&X6\n\n\n Ind8psndsnt Iabor8tory Locstion of Wh8r8 the labomtory tmt is performed\n\x0c APPENDIX E\n\n\n\n Some Carrier Methods of Processing PA Claims\n\n\nOne carrier reviewed (BC/BS of Minnesota) assigns a provider number (e.g., POO5)to\nphysician assistantsalong with a group number to the clinic or group employing the\nPA. Those responsible for filing any claims are told to include the PA\xe2\x80\x99s number in\nitem 24H of HCFA form 1500 to indicate the performing provider. The supervising\nphysician\xe2\x80\x99s name is to be placed in item 24C and the name and provider number of the\ngroup or clinic is to be included in item 31.\n\nSome carriers like Nationwide of Ohio, do not assign a number to a PA, but rather\nflag a supervising physician\xe2\x80\x99s number (e.g., Ohio uses flag 54) to indicate to the\nclaims staff that the provider number department has verified that a licensed PA works\nfor this provider. A carrier official said that claims should indicate who the PA is that\ndid the service, but is not required for the claim to process. However, even if the PA\nis identified on the claim, a claim representative processing the claim could only\nascertain from the computer that the supervising dot has a PA employed. Only the\nFlag indicator is accessible. Consequently, if a physician employed more than one PA\nor a new PA replaced the PA which was approved by the provider number\ndepartment, the carrier would have no knowledge of what PA performed the service.\n\nLike Nationwide, Aetna of Georgia does not assign a number to PAS. However the\ncarrier does require the claim to indicate the physician assistant who\xe2\x80\x99s qualifications\nare verified at the time of claim processing. A claim representative is instructed to\nenter the first 4 characters of the physician assistant\xe2\x80\x99s name, the first initial of the first\nname, two spaces and the first three initials of the supervising doctor\xe2\x80\x99s name. If the\nphysician assistant had been previously credentialed by the carrier (license or\ncertification verified) the claim would process. However, if such a mnemonic check\nreveals the physician assistant has not been set up for this physician, the claim will\nsuspend and an application will be sent to the submitter of the claim.\n\x0c APPENDIX i\n\n\n Carrier Registry (UPIN) Activity\n Total UPINs ( Average Hecords1\n\n\n\n\n I .T\xe2\x80\x9d\n\n\n BC/BS of Pennsylvania (a) 1.48 I\n Aetna Life and Casualty (e) , ,- , . . ,--- -,--- 1.48\n Bc/Bs of Kansas 1 KS1 5,673 3,801 1.49\n Aetna Life and Casualty (e) .NV\n ..\n 1 -,---\n 3.098 2,068 1.50\n\n\n\n\n I=\n Blue Shield of Western New York NY 19,931 13.232 1.51 \n\n BC/BS of Nebraska NE 4,447 \n\n BC/BS of Masaachusetta (a) NH 4,331 \n\n Blue Shield af Iowa IA 12.305 \n\nk lllieor\n -.- ID\n BCIB! 5 of Pennsylvania (a) DC -,.-- , 1.64\n ..-. I\n1 General American Life Insurance Co. MO _IQAlR I 1.64 \n\n I ..T,- , .-,.- , 1.70 \n\n 12,030 I 6,990 1 1.72 \n\n 1.75 \n\n 1.75 \n\n Travelen 1 MS 1 7: 4 7c \n\n BC/BS of Mervland 1 MD 1 18.1 10,539 I 1.76 \n\n BCIBL -. . --- I TXI\n .__ , __,_. . I\n 6[1.671 33.6!34\n __,__. I 1.79 I\n BC/BS of Kanraa Cii MO 1I 7.259\n . ,-- ,I AOR!\n .,--- 1.80\n Equicor (a) TN 20,- I 11,117 1.BO\n BC/BS of Michigan Ml 1 32,785 1 18,079 1.81\n1 Associated Insurance Company ( IN I m.&i!5\n -_, .-- I 11,104 1.84\n Heaith Care Service Corporation IL sP.?MI\n -,-- 28,397 1.84\n BC/BS of Pennsylvania (a) DE 2,637 IMOI\n I,-\xe2\x80\x9c\xe2\x80\x9d 1 1, .-.\n R7 I\n BOBS of Kentucky KY 14,811 7,912 \xe2\x80\x99 1 n7\n I._,\n I\n Empire BC/BS NY 76,057 39,950 i , 1.90 1\n Transamertca Occidental Life Ins. Co. CA a- 36,542 1 1..--\n 87 I\n BC/BS of Massachusetts (a) MA 47,909 24,749 1 1.94 I\n California Blue Shield CA 104,248 532\n Equicor (a) NC 28,667 13,9c- (\n BC/BS of Florida FL 71,825 =,= I\n BC/BS of Arkansas (a) AR 11,147 5,216 1\n BC/BS of Arkansas (a) LA 19,900 93 15 2.14\n BC/BS I of Alabama AL ._,___\n lQ.fFi!i I -.-.\xe2\x80\x988\n Q.Oi 2.19\nI Nationwide Mutual Insurance Co. (a) OH 53 AS9\n --, .- ,1 32\n --, RnA\n --- ( 7 70\n 1of Minnesota MN 9,137 1 4,027 1\n wide Mutual Insurance Co. (a) WV 10,016- I .~~~ 1,\n 4.255\n ; of South Carolina SC 19.2!74 7,733 I\n I10 I 703,102 1\n\n - letters next to carrier names distinguishes between same carrier but different management control.\n Source: From data supplied the O/G from the Physician Registry 12/9o.\n\x0c i\n\n\n\n APPENDIX 6\n\n\n\n\n\n Blue Cross and Blue Shield of Alabama\n\n\n\n\n Eauicor I ID I 30 I 10 I 5 I 5 I 1\n\n\n\n\n\n Blue Cross and Blue Shield of\n\n\n\n\nTravelers Insurance VA l l 5 10 t\nWashington Physicians Service WA 130 20 5 5 15\nWisconsin Physicians Service WI 100 25 7-10 7-10 .\n\na\n This value refers to # assignment for Pennsylvannia only and to newprotiders from out-of-state.\nl Indicates the cam\xe2\x80\x99er did not know\nSource: Cam\xe2\x80\x99er suppfied approximations (5/90)\n\x0c APPENDIX ki\n\n\n\n\nCarrier Counts of Some Part B Providers \n\n\x0c Carrier Physician Counts by Type and State\n State 8 Carrier MDs/DOs Dentists Podiatrists Chiropractors Optometrists Clinics\n AL BIB 6,537 1,609 76 364 60\n AR BIB l 3,565 46 301 269 252\n CA BS 35,634 725 1,357 3,721 1,560 1,770\n CA TO 21,771 6,194 1,590 3,550 ia 3,069 12 45\n CO B/B 7,410 1 1,794 1 1431 762 1 3641 131\n CT Tra 12.195 1 659 1 413 I !a11 4861 239\n i DC\n -- B/B\n -.- PA\n ___ 1 *I 5.234\n -,--\n --,--- I\n I 128\n .-- I 124\n ..- I\n .-. 101\n --.\n .-. I 1261\n .-- -jr 5\n DE B/B PA * 1,352 I 14 1 341 561 55 1 i4\n FL B/B l 26,767 99\n GA Aet\n HI r.\xe2\x80\x9c.\n Am\xe2\x80\x99 i z- 20 125 123\n- IA BIB l 4,640 343 131 696 536\n ID / BIB\n -.- 1 l 1,210 16 26 165 74\n IL BIB l 17fc7A RR!! RRA l!iR6 Ifs7 Q6R\n IN BIB 7,923 130 2901 590 1 660 1 320\n ,KS B/B 4,146 1,042 61 1 499 1 3671 373\n KS B/B KC l 970 29 291 loo I 361 2\n KY B/B I I 8.&i\n -,--- 1 3%\n --- I 95\n _. I 4321\n .-- A;;\n .-. 1 Qi\n -- 1\n LA BIB AR t 6,761 526 75 512 342 416\n MAA BIB l 19,609 4,256 694 607 1,056 450\n MI D B/B 6,396 1,475 227 196 221 342\n MLn R/q\xe2\x80\x98,\xe2\x80\x99 PA l 3,443 93 100 71 69 47\n ME B/E !MA l 2,401 67 56 161 190 66\n MI BIB l 23.670\n --I-- - 3.088\n -,--- 798\n . -- 1.768\n .,. -- 16AA\n .,_. 547\n - .-\n,MN B/B 5,915 613 63 616 439 395\n Ml N Tra 2,695 70 75 440 100 \n\n M( 3 BIB l 2,829 62 57 342 177 4\n\n MO G-A 4.512 338\n --- 118.- a!39\n --- 377\n -.- 107\n\n .-.\n MS Tra 2,730 1 65 1 321 170 1 1661\n MT BIB l.R45 I Ql I 7R I 1RA I 1RAl\n NE\n NC\n\n\n\n\nI No l indicates\n- Data supplied\n the approximate number ofprotider\n by canters to the OIG (10/89).\n records (i.e., numbers).\n Data applies to 47states and the District of Columbia.\n I\n\n\nI\n- Blank cells indicate\n- Clinics are providers\n the carrier has no providers\n listed under HCFA specialty\n with the indicated\n \xe2\x80\x9870\xe2\x80\x99 (multispecialty\n specialty\n clinic).\n or no counts were provided.\n I\n\x0c Carrier Nonphysician Counts by Type and State\n Physician Nurse NlJW! Physical Occupational\nState 81Carrier Assistants Audioloaists Anesthetists Midwives Therapists Therapists\n\n\n\n\n I , I --\n I l II 437 1 673 1 I 1 !Dn I I\n t l 331 117 I . 1\n\n\n\n\n I.. . -- --\n 3 l 41 l!.\xe2\x80\x9d , I\n B 50 1\nMD B/LB _PA__ t 3 13 I 31 49 4\nME B/B MA l ii 50 36\n\nMI B/B l 365 1,313 1 96\nMN B/B 4 474 16\nMN Trr m I I\n E\n \xe2\x80\x9c,\n 17EI,\xe2\x80\x9c, I\n 7fl\n -1 ,\n I\n\n\nMO B/LB l 61 236 I I 91 2\nMO GA I I 201 1:ii I II 391\nMS Tra ii1 ii 1 1\nMT B/B 22 14 26 3\nNE B/B KS 34 6 193 53 2\nNC EcpTN~~1 l 119 13 972 64 2\nND B/E I l .-\n 10 .--\n 135\n I 4\n I\nNH B/B M,A (*I 201 641 461 51\n l\nNJ BIB PA 531 61 11 172 1 6\nNM AetnKw.. II II II ml I MI I ml 26 I\n I\n AZ l I 12 I 19 1 ,.;I\n\n\n\n\n I\n l\n I 481 23 1 7\n-_ _~.\nVA Tr.\nVT B/L .-... I I .\nWA PS 67 I 2081\n --- 21 264 I I\nWI PS I 361 1431 -44 1 I\nWV NL IOH t 27 1 10 I 27 1\nWY- \xc2\xad\n f Equ l 1 I 31 I 20 1 I\n\x0c _-\n Carrier Nonphysician Counts by Type and State (cont.)\nI 1 Portable 1 Clinical ( Physiological 1 1Other Supply*\n State & Carrier Ambulance X-Ray Labs Labs DME* (e.g., drug) 1\n Al B/B 162 2 61 21 595\n AR B/w\xe2\x80\x98R t 236\n --- 5 47 2 726\n CA BS 150 5i 1,065 69 6,161 473\n CA TO 499 43 594 1,247 3,009\n CO BIB 171 6 57 51 13=\n CT Trr 105\n .-- 12 291 722 366\n l 11 I -26 1 6 220 237\n PA 1 *I 77 I I 11 56 176\n\n\n\n\n1 IN BIB I 290 12 135 120 1,\n 7 1 166 701 1\n KC t 6 1 5 135 53\n I I 767 10 76 13 1.272 949\n\n , .. . I I .wll\n .-- I 11.\n . I 17s\n -- I 113 I 2.231 1 1.9911\n I". , ." -.\xc2\xad\n rn D* I *I rl Al 45 7 47\n 20 16 \t 292 252\n C77\n\n\n\n\n B KS I I 241 1 21 16 1 I 1,196 I 21\n\n\n BMA l 93 1 1 I 261 41\n I I . . , . . , . .- -- , -.- _,-_ \xc2\xad\n\n *nK I I (I7 I 71 RQ I I 1921\n\n\n\n\nTX B/E 3 25 1 365 1 991 3260 1 9631\nTN Equ l 176 5 202 92 166 1,765\nUT B/B 66 2 18 446\nVA Tra 64 6 34 13 211 643\nVT B/B MA 69 4 , 129 136\nWA PS 177 107 515 1,039\nWI PS 361 6 24 249 1,251\nWV NMOH l 152 4 56 494 243\nWY Equ t 63 27 32 129\nTotal 10,600 553 6,583 1,725 45,653 36,996\n\n\n\n\nI\n l Other Supply consists of counts supplied by carriers under HCFA specialty code 87. DME consists of counts\n supplied under HCFA specialty codes 51-58. During the course of contacting some carriers, we discovered some \n\n carriers include DME under specialty 87 rather than specialty 54 as prescribed by HCFA. I\n\n\x0c'