Soon we will be introducing legislation to strengthen Medicaid program integrity by requiring certain individuals who provide reimbursable Medical Assistance services in the home or community to obtain and use a National Provider Identifier, or NPI.

This proposal addresses a long-recognized gap in Medicaid claims oversight. Investigators in the Pennsylvania Office of Attorney General identified this as a major contributor to fraud risks in 2019, recommending that Medicaid claims identify the actual individual providing the service by requiring that individual’s NPI to be included on the claim.

Currently, many claims are submitted by an agency, fiscal intermediary, or provider organization, while the individual worker providing the care may not be clearly identified. This makes it harder to verify who provided the service, when it occurred, and whether it was actually provided.

The legislation would require certain claims to include the individual provider’s NPI, the Medicaid provider number, each date of service, and the start and end time for each service provided.

CMS has recently emphasized the revalidation of high-risk Medicaid providers, identifying those without an NPI as a specific concern, and Pennsylvania’s Department of Human Services has publicly acknowledged the need to identify all providers, and taken steps in this direction (for instance with doulas and community health workers) with the intent that in the future, anyone touching a patient will need to have an NPI.

By improving claim-level transparency, this bill will help preserve Medicaid resources for the vulnerable Pennsylvanians and necessary services these programs are intended to support.

Please join us in cosponsoring this legislation.