Are Your Doctors Who They Say They Are?

Understanding how each physician’s specialty is properly registered.

As you might know, one of my primary projects is predicting the likelihood that a particular provider may be audited – and if so, which procedures, codes, and/or modifiers are most at risk.

To a large degree, this type of target acquisition conducted by the government and private payers relies upon a core benchmark of peer-based utilization, and while that may not be the entire story, it is the introduction for sure. This initial benchmark is determined based on the specialty of the provider being reviewed, and so it would stand to reason, under the GIGO (garbage in, garbage out) assumption, that if the specialty is wrong, then everything that follows is wrong as well.

For example, let’s say that there is a physician practicing as a cardiologist. An organization lists him or her as a cardiologist, he or she is promoted as a cardiologist, and the billing is done under the guise of a cardiologist. This cardiologist is billing for a ton of procedure codes, including 99234, 99235, and 99236 (“Pm device interrogate remote,” “Dev interrog remote 1/2/mlt,” and “Pm/icd remote tech serv,” respectively).

In fact, let’s say that these make up the first-, second-, and third-most often reported procedures by this cardiologist. As a result, this cardiologist gets selected for an audit, because based on the Medicare peer utilization data for cardiologists, these procedures are ranked 28th, 26th, and 25th, respectively. In fact, nationally, these procedures account for about 1.5 percent of all of those reported by cardiologists. 

But wait! Let’s say that instead of a cardiologist, this physician is actually a cardiac electrophysiologist. Now, the picture looks much different, because, for that specialty, those three codes are ranked as the eighth-, fifth-, and fourth-most often reported, with a total distribution of just over 14 percent, or over nine times as often as cardiologists. That makes a huge difference because when compared against other cardiologists, this provider seems to be a bit of an anomaly because the utilization is way out of whack. But when compared to other cardiac electrophysiologists, the provider looks pretty much normal. I could give you dozens of examples showing that this is not just a theoretical problem, but has caused issues for many physicians and practices in real life. 

So who cares, really? Well, you should, for one, because the payers do. Where do you think the benchmark data came from? They might be from the national Medicare fee schedule database or the national Medicare claims database or some private payer database, but no matter which source, they are all basing their benchmarking decisions on specialty, and the specialties come from one of two places: the National Plan and Provider Enumeration System (NPPES) database or the Provider Enrollment, Chain, and Ownership System (PECOS) database. And sometimes, it’s a crapshoot to know who uses which one. 

For example, in conversations with folks who conduct the annual Comprehensive Error Rate Testing (CERT) study, I was told that they rely upon the NPPES database. But for determining anomalies under the Fraud Prevention System (FPS), the specialties are associated with the PECOS database.  The Medicare Administrative Contractors (MACs) tend to rely on the PECOS database, while I have heard that private payers rely more on the NPPES database. So, what’s a physician to do? The first step is to take a look at each of these and ensure that each physician’s specialty is properly registered. For the NPPES database, go to and type in the National Provider Identifier (NPI) number. There are instructions that will tell you how to update your primary as well as secondary taxonomy codes. For the PECOS database, go to and follow the online instructions. 

I can tell you that, based on the tens of thousands of physicians for whom I have conducted risk assessments, just over 10 percent have been registered under the wrong specialty in one or both of those databases, resulting in audits – expensive and resource-intensive audits – that never should have occurred. It’s not just a small error, and I have seen cases for which what the practice thought was the physician’s specialty was different from the PECOS database AND different from the NPPES database, which can make it very confusing when trying to understand why a provider has been subject to an external audit.

You know the old expression, “fool me once, shame on you. Fool me twice, shame on me”? I can’t think of a better application than this.

And that’s the world according to Frank.


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