Medicare’s Data Release Poses Risks to Nurse Practitioners

Last year, in a highly controversial move, the Centers for Medicare and Medicaid Services (CMS) released data surrounding payments made to medical providers. This year, CMS has also included Medicare Part D prescribing information in the data set. The release includes information regarding CPT codes billed, reimbursement rates, and medications prescribed by individual healthcare providers, nurse practitioners included. Are there any unintended consequences of this move by Medicare for nurse practitioners?

As the cost of healthcare increases, CMS is putting pressure on medical providers to watch the proverbial wallet in delivering patient care. Releasing provider payment data is part of that plan. With transparency when it comes to how much physicians and nurse practitioners are paid, Medicare hopes high billers will be forced to modify their habits. The organizations also hopes the recent inclusion of numbers when it comes to prescribing will encourage providers to stick to generic medications or inexpensive branded alternatives.

While most applaud transparency in healthcare, releasing Medicare Part D data dose pose risks for healthcare providers, nurse practitioners included. First, access to this data gives other entities the right to use this information. For example, state attorney generals may review provider’s prescribing information to look for red flags when it comes to prescribing habits. CMS, however warns that Medicare Part D data isn’t necessarily reflective of a provider’s prescribing patterns.

In some cases, numbers released by Medicare are exactly what they seem. Providers writing large numbers of prescribtions for narcotic medications or who have disproportionately high numbers of claims may be charged with fraud and rightly so. Some providers, however see few Medicare patients. Nurse practitioners working in pediatrics for example, may only have a handful of Medicare claims. An audit of Medicare data would inaccurately reflect billing and prescribing habits given the small sample size of this provider’s Medicare population. In other cases, a provider’s numbers may be skewed as they see a majority of privately insured patients relative to their Medicare patient population.

The second risk the release of Medicare Part D data poses to nurse practitioners concerns the prescribing of controlled substances. When a controlled substance is prescribed or ordered, the ordering provider must be the one to sign for the medication. This data is easily misrepresented, especially with electronic documentation systems. With the release of the first set of Medicare payment data last year, this issue came to light. Some providers appeared to be prescribing large numbers of narcotic medications or billing in high amounts becasue multiple providers within the same practice were prescribing and billing under a single provider’s name. While these cases may seem like simple documentation errors, Medicare views this as falsifying medication orders and making fraudulent claims. 

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Given Medicare’s new policies regarding the release of prescribing and billing information, healthcare attorney Alex Krouse recommends that nurse practitioners take a few precautions in their practices. First, review your personal information released by Medicare. If your numbers seem disproportionately high, low, or otherwise incorrect, you may be able to report this in a safe manner to mitigate an accusation of fraud. This is also a sign that your practice may need to adjust the way it’s systems and protocols are set up, at least in regards to prescribing and documentation.

Second, Krouse recommends paying close attention to nuances in state laws when it comes to prescribing controlled substances, particularly for pain management. State laws are very specific when it comes to prescribing these types of medications. Maintain an active understanding of these guidelines. If multiple providers work in your practice, it must be clear who is prescribing and documenting in each patient encounter. Orders or prescriptions for medications must be executed under the name of the prescribing provider. The way you order and prescribe medications must be in compliance with both state and federal regulations to be accurately represented in the CMS database. As prescribing information becomes more readily accessible, regulatory boards are paying attention to make sure providers are in compliance with these regulations. 


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2 thoughts on “Medicare’s Data Release Poses Risks to Nurse Practitioners”

  1. Would the implications be the same for those electronic order entry systems that default to a physician name for prescriptions written by NPs for durable medical equipment, supplies and services, like physical therapy?

    Could pharmacists, suppliers and therapists be held accountable by CMS if they are knowingly, or unknowingly, accepting prescriptions that default to a physician name and billing under that name?

    What is the primary source–a Code of Federal Regulations location, perhaps–of this CMS policy?

  2. For electronic entry systems, it depends. The problem is that CMS permits orders by NPs for some items, and for others, it does not. If it defaults to one type of provider, this could be problematic. Pharmacists have a duty in some circumstances to ensure that the prescription is correct though. An example would be for controlled substances. The problem is that there are various final rules, regulations, and laws on the topic. Generally speaking though, a pharmacist has a duty to confirm the prescription is correct. If you have further questions please feel free to let me know.

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