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NPI a Key to Fraud Prevention

July 17, 2019


The National Provider Identifier (NPI) is a key to preventing fraud in Medicare put in place by the Centers for Medicare and Medicaid (CMS) Final Rule on Fraud Prevention. It is designed to ensure quality care because it allows the verification of credentials of a provider who is treating or prescribing and ordering equipment and supplies. It is expected to save taxpayers an estimated $1.6 billion over a period of 10 years.

As an important data source in the effort to protect patients, as well as prevent fraud, the NPI number matches an entity or provider to electronic transfers of information in health care. Checking an NPI number when screening and monitoring for credentialing and enrollment of providers, as well as referrals of supplier entities, will provide a critical data point for full transparency.

Some ways NPI numbers are used fraudulently are; a provider or entity using multiple NPI numbers, which would indicate medical identity theft, or an excluded provider using an affiliated entity’s number to continue practicing or prescribing. The NPI number can also help identify suspicious ordering behavior which could suggest fraud. It is critical to deactivate the NPI number assigned to a deceased provider, a dissolved entity, or if theft is suspected to mitigate fraudulent behavior.


The National Provider Identifier (NPI) is a standard that establishes a unique health identifier for health care providers. The final rule was enacted by the Department of Health and Human Services (HHS), Office of the Secretary, Centers for Medicare and Medicaid (CMS) as part of the Health Insurance Portability and Accountability Act (HIPAA) Administration Standard. The NPI is an Administrative Simplification mandate of HIPAA that ushers in effectiveness and efficiency with regard to electronic transmission of private health information.

The Centers for Medicare and Medicaid (CMS) requires an NPI for all HIPPA covered providers and entities spanning both government and the private sector, as well as a provider or supplier that bills Medicare. All other individuals or entities that meet the criteria of a health care provider as outlined in 45 CFR 160.103 may obtain an NPI number. Individuals and entities apply for NPIs through the CMS National Plan and Provider Enumeration System (NPPES).

The 10-digit number does not contain any information that would indicate state of practice, taxonomy, or payer type. It is designed to link a provider or entity to electronic transactions that include: claims, encounters, eligibility, claim status inquiry, electronic remittance advice (ERA), precertification add, and NCPDP for pharmacy. It is a prerequisite to enrolling with Medicare.

The NPI number replaces an older system where identification numbers were assigned to providers and supplier entities by health plans. Without standardization, providers and entities would have different identification numbers for each health plan and sometimes the same number would be assigned to different providers by different plans. The NPI number is key in claims submissions as well as facilitating the tracking of current and historical transactions to a single provider or entity through a single NPI.


The NPI number is accessed by Verisys as part of the screening, verification, and continuous monitoring process for health care credentialing and compliance. It is one of the thousands of primary sources that comprise CheckMedic®, Verisys’ data technology platform that creates a portable, secure, digital profile for each individual or entity within an organization.

As in all searches, one key-in error such as not knowing the current name of the provider in the event of a legal name change, or typing in the wrong spelling, can lead to inaccurate search results. Verisys takes extra steps to match an NPI number with 99.5% accuracy to the individual or entity. With an aggregated database of more than 320 million records, there exists many hundreds of data points that correctly identify and match an individual or entity to records. By implementing a scientific approach to identity resolution using sophisticated algorithms, Verisys delivers close to 100% accuracy nearly 100% of the time. Having a complete view of health care providers and entities is key to mitigating fraudulent activity and elevating the level of health care across the country.

Susen Sawatzki Written by Susen Sawatzki
Healthcare Industry Expert
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