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The NPI Challenge for Medical Practices February 13, 2007.

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Presentation on theme: "The NPI Challenge for Medical Practices February 13, 2007."— Presentation transcript:

1 The NPI Challenge for Medical Practices February 13, 2007

2 2 Discussion Points  Background  The NPI Challenge  Preparing for the NPI  Recommendations  Additional resources

3 3 Background

4 4 NPI Purpose The purpose of the National Provider Identifier (NPI) is to uniquely identify a health care provider in standard transactions, such as health care claims. It will replace other identifiers such as the UPIN, payer identifiers, CHAMPUS, Medicaid numbers, etc.

5 5 NPI Purpose cont. NPIs may also be used to identify:  Health care providers on prescriptions  Internal files to link proprietary provider identification numbers and other information  Coordination of benefits between health plans  Patient medical record systems  Program integrity files, and in other ways.

6 6 Who needs an NPI? All covered health care providers that need to be identified in a health care transactions –For example, operating physician, attending physician, rendering provider, referring provider Not all eligible health care providers need an NPI, even if they work for a covered health care organization –For example, in a covered hospital, not all nurses need an NPI, because they don’t need to be identified in a health care transaction

7 7 NPI Compliance Date May 23, 2007 is the compliance date for large providers. Small providers have until May 23, 2008 to comply with the regulation. Remember – NPI identifiers are designed to be lifelong identifiers and changed only in the case of fraudulent use of the identifier.

8 8 If I haven’t obtained my NPI where can I get information about the process? A helpful tool that provides an overview of the NPI and the application process for obtaining an NPI is available at

9 9 The Challenge

10 10 Payer-Assigned, Proprietary Identifiers will be replaced with Provider-Defined, National Identifiers May 2007 deadline for NPI compliance - the industry is just now starting to consider its impact Healthcare Payers may have misjudged the magnitude of the NPI/PIN cross walking effort –What are the business challenges? –How will those challenges impact the bottom line if not successfully addressed? –What are the options to address these impacts? The NPI Challenge

11 11 Pre-NPI HIPAA transactions with Provider ID Number (PIN) –ID issued by health plan –Single provider could have multiple PINs –May contain embedded intelligence –PIN typically drove business rules –PIN mapped to specific contracts and business edits Post-NPI HIPAA transactions with National Provider ID –ID issued by Enumerator –No embedded intelligence –HIPAA work to date will not help with this problem Provider Type 3556760098334 Provider Specialty Contract Number Identifier Embedded Intelligence

12 12 NPI Business Challenges Payer’s backend systems (Claims, Eligibility, Enrollment) rely on Provider ID Number (PIN) for proper routing of the transaction Must associate the NPI to PIN in order to trigger backend system logic –One to one, One to many, Many to one, Many to many –Business rules vary by plan –Determination of proper contract terms is problematic A sophisticated validation and matching process is required NPIPIN PAYER’s BACKEND SYSTEM ###

13 13 Challenges during the NPI Transition –Dual standards –Archived data, medical records –Distorted, lost statistics –Rating/fee changes –Trading partner testing and migration

14 14 Challenges during the NPI Transition –Information processing issues: –Matching current provider/identifier to the NPI. –Designing and implementing new data flows and uses without proprietary number(s). –Accurate subpart determinations. –Keeping on top of modifications to the requirements.

15 15 Challenges during the NPI Transition –Correlation of NPIs to proprietary IDs (which represents a reimbursement arrangement for that particular provider). –Cross walking – mapping possibilities One NPI to one proprietary ID One NPI to several proprietary IDs Several NPIs to one proprietary IDs One NPI no proprietary ID

16 16 NPI Business Challenges Failure to make the correct match between NPI and PIN may result in various downstream issues: –Overpayment of a claim Retraction of overpayments, adjustments and subsequent repayments to the health care provider immediately impacts the health plan’s bottom line –Underpayment of claim Recalculation of underpayments, adjustments and subsequent repayments may also involve heavy fines, violation of state prompt payment laws, possible law suites and provider dissatisfaction –Incorrect eligibility response Improper responses to eligibility inquiries may result in provider over/under billing, patient dissatisfaction (especially if erroneously forced to pay a higher co-pay, billed for non-covered charges that should be covered or told to use specific ancillary facilities ( 3rd party labs, radiology clinics) that aren’t appropriate) –Sponsor dissatisfaction Eventually patient dissatisfaction will lead to employer dissatisfaction as mishandled transactions are reported to HR by disgruntled employees

17 17 Identify the Impacts in your organization from NPI initiatives –What are the business challenges? –How will those challenges impact the bottom line if not successfully addressed? –What are the options to address these impacts?

18 18 Potential Impacts in your organization from NPI initiatives Software/hardware Reimbursement/Contracting Procedures/Treatment Policies Training Forms Statistics/Reporting/Research Transactions Transition impacts and historical data

19 19 Payer Software Impacts Changes to format, logic, business rules –Screens, CB’s, files, reports, queries, edits, mapping. –Adjudication, reimbursement, other logic –Authorization, actuarial, case management, utilization management Vendor software –Groupers, special edits (e.g., medical necessity), statistics, reference Other changes –OCR, Web, etc and extensive testing MUST be performed for these changes.

20 20 Provider Software Impacts cont’d Impacts to software or tools built in- house –Scheduling –Billing –Claims Submission –Finance/Performance

21 21 Vendor Software Impacts Software changes as described earlier –Decision support systems –Billing/Practice Management –Medical Necessity –Managed Care/HEDIS or other quality reporting –Documentation updates –Contractual updates –Implementation, rollouts, conversion, training

22 22 Impacts on Reimbursement Payer –Impact to DRG’s, line pricing by procedure, contract negotiations, fee schedules, revise and distribute materials Provider –Impact to fee schedules, contracts, new billing software, coding changes, extensive documentation, practice costs, cash flow Employer –Impact to contracts, special customer arrangements, coinsurance, riders

23 23 Procedures Impact Payer –Documentation, error corrections –Timeliness, fraud, case management policies –Reimbursement policies, underwriting Provider –Treatment policies, authorizations, referrals –Coding, increased documentation Other –Clearinghouse, TPA, Lab, Pharmacy, Employer Anyone dealing with diagnosis/procedure codes

24 24 Preparing for the NPI

25 25 Preparing for the NPI Transition Questions Providers should ask themselves: How will your mainframe system house the NPI for use in claims? –Will your practice management system require changes to accommodate the new number? –Will these system changes impact your paper claim capability? –Will you have enough storage space for the NPI numbers?

26 26 Preparing for the NPI Transition Questions Providers should ask themselves: –When will your vendor make these changes? –Will the timing of the vendor updates coincide with the compliance date? If not what alternative measures are available for compliance? If you do not have an automated alternative, do you have enough staff to hand key the information on claims? Or can you hard code the information in your system until the updates are ready?

27 27 Preparing for the NPI Transition Questions Providers should ask themselves: –Are there possible office procedure changes that you will need to make? –If you must make procedure changes, you must update your policy and procedure manual to reflect these changes. –Notify and train staff and providers of procedure changes and how it will affect their day-to-day activities.

28 28 Preparing for the NPI Transition Questions Providers should ask themselves: –Have you notified you’re HIS vendor, clearinghouse, billing agent and each of your payers of your NPI(s)? –You must contact each payer to determine the procedure for submission of the information. Be sure to include your legacy identifiers with your NPI notification.

29 29 Preparing for the NPI Transition Questions Providers should ask themselves: –Have you a nalyzed your current Payer Contracts? –Payers may require re-enrollment. When you research the method for NPI notification, ask if there are additional requirements, such as re- enrollment. –Some payers may require the submission of NPI(s) before the May 23, 2007 compliance date. They can do so as the regulations to do restrict this practice since it is a business decision to make this requirement.

30 30 Preparing for the NPI Transition Questions Providers should ask themselves: –Have you a nalyzed your reimbursement systems/pricing systems/provider contract systems? –How is your system going to maintain historical claims data?

31 31 Reimbursement depends on… Preparatory work and if providers have: –Analyzed current Payer contracts. –Registered the NPI(s) with the Payers and SSI. –Identified NPI subparts accurately. –Updated their mainframe systems to capture NPI information that can be transmitted on claims.

32 32 Reimbursement depends on… Preparatory work and if providers have: –The Payer has correctly cross-walked legacy and NPI identifiers. –They have provided all NPIs to the payer. –They have appropriately applied the correct NPI to the claims. –Identified additional information needed on claims to assist with correct reimbursement, e.g. rendering location, taxonomy codes, etc.

33 33 Recommendations –Apply for the NPI as soon as possible and notify SSI and your Payers. –Watch for information from the health plans with which they do business on the implementation/testing of NPI’s in claims, and other standard transactions. –Know the Payers NPI scheduled roll out dates.

34 34 Recommendations –Review laws in your state to determine any conflicts or supplements to the NPI. –Identify collaborative organizations in your area working to address NPI implementation issues and on a regional basis among the physicians, hospitals, laboratories, pharmacies, health plans and other impacted parties.

35 35 Recommendations –Ensure alignment with CMS timelines to be ready to transmit NPI on claims by May 23rd. –Monitor CMS Medlearn Matters and other FAQs on the CMS website:

36 36 Additional Resources HIMSS: id=179 id=179 CMS Centers for Medicare and Medicaid Services: /. / CMS NPI Enumerator website:

37 37 Acknowledgements Prepared by members of the HIMSS Ambulatory Business Systems Integration Task Force and HIMSS AFECHT Advisory Council. A special thank you to:  Mary Hyland AVP Regulatory Affairs, the SSI Group, Inc  Ellen Van Buskirk, Kean Worldzen  Catherine Schulten, Director, Industry Relations-Healthcare for EDIfecs

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