The NPI Mandate Approaches as Confusion Continues

In May 2007, the Centers for Medicare & Medicaid Services (CMS) gave health plans and providers an additional year to prepare for the mandate that all electronic health care transactions include National Provider Identifiers (NPIs) in lieu of legacy IDs. Now the May 23, 2008, compliance deadline is approaching fast, and there is general agreement that the industry “is facing major disruption of business operations” after the contingency deadline ends, according to the Workgroup for Electronic Data Interchange (WEDI). Research by WEDI indicates that a very low percentage of NPI-only transactions are being submitted.

“Right now, there is a high level of usage of both NPIs and legacy IDs, which will not be allowed starting May 23,” said Kymberly Eide, category director of Provider Data Solutions for Ingenix. “Many payers are not prepared for NPI-only transactions because they have not fully integrated the NPI from a systems perspective. Without the complete NPI data set and full transition to NPI-only processes, many transactions are bound to be rejected.” Medicare and Medicaid claims will be impacted most directly, but there may also be a ripple effect throughout all claims processing.

“Many health plans ventured into NPI implementation thinking they could easily integrate CMS’ National Plan and Provider Enumeration System (NPPES) data into their databases. However, most have encountered setbacks because integrating and matching accurate NPI data from NPPES can be challenging,” Eide continued. “This process can become extremely cumbersome unless health plans have robust processes for integrating and matching data to build the needed crosswalks to the NPPES file.”  

NPI looming since 2004

The NPI concept was introduced more than a decade ago, when the Health Insurance Portability and Accountability Act of 1996 (HIPAA) called for a standard, unique health provider identifier to be used in all HIPAA transactions. In 2004, a CMS final rule established this identifier as the NPI.

Except for small health plans, the regulatory deadline for full NPI compliance was May 23, 2007. However, in April 2007, CMS announced that due to reported delays in NPI implementation, it would not impose penalties on covered entities – health plans, health care clearinghouses and health care providers – that deployed NPI contingency plans through May 23, 2008.

In a March 28, 2008, FAQ posting on the CMS Web site, the agency stated its intention to lift the enforcement leniency policy as scheduled. “In sum, on May 24, 2008, all contingency plans should be complete and all covered entities are expected to submit and accept the NPI on standard electronic transactions,” declared the FAQ.

NPI implementation problems persist

Over the past year, plans and providers have struggled to achieve NPI compliance, but many problems remain. At a recent discussion of NPI issues among WEDI members, a list of industry concerns included the low percentage of NPI-only transactions, significant crosswalk glitches, a lack of testing on transactions other than claims and claim payments, and a dearth of secondary provider NPIs.

“There is a perfect storm brewing here,” Eide said, “and one of the most pervasive problems is confusion.” She explained that many plans are building complex crosswalks that may not be fully functional because the information in their databases and the NPPES database is not complete or compatible.

“When you are trying to match List A with List B and the two lists don’t have compatible crosswalks for matching, it simply isn’t workable,” she said. “Bridging to NPPES data and integrating the NPI numbers is more complicated than most plans thought it would be.”

Some plans are attempting to manually connect their providers with the appropriate NPIs, which can be a time-consuming, expensive and error-prone task. “If you have 300,000 providers, that’s a tremendous amount of research, correspondence and data entry, and time is running out,” Eide commented.

After May 23, NPI is required for all HIPAA-standard transactions. Only the NPI will be accepted in all primary and secondary provider fields for all HIPAA electronic transactions, paper claims and standard paper remittance (SPR) advice. The use of Medicare legacy identifiers will result in rejection of the transaction by CMS.

“If plans have to manually validate NPI numbers submitted on a large number of claims, they may experience delays in claims processing,” Eide cautioned. “Also, the cost of processing these claims may increase from pennies to dollars. Will everything shut down? No. But there will be a lot of confusion, late payments, excess call center activity and headaches.”

Advanced data tools can simplify implementation

Plans trying to overcome NPI implementation obstacles on their own may not realize that they can complete the process in a faster, more accurate and cost-effective way by looking outside of their organization for help, Eide remarked. “Ingenix uses the most sophisticated methods to match providers to their NPI numbers, and offers several options for transitioning to a fully integrated NPI system.”

The Ingenix Provider360™ NPI Integrator can help plans accelerate or complete their transitions by offering data that can be accessed in several ways depending on their needs, she indicated. “Ingenix offers both self-service and full-service options. We can take a plan’s provider data records, match them to the right NPI number and return that file with the NPI integrated. Alternatively, we can provide a set of data that includes NPI and other legacy crosswalk identifiers to allow the plan to integrate the NPI themselves,” said Eide.

Ingenix leverages a comprehensive referential database which integrates over 600 data sources and is verified through extensive provider phone and fax outreach. “Our data processing tools and analytics engines enable us to match a plan’s data to our comprehensive provider database, which already includes the NPI numbers. Through this process, we can create the necessary crosswalks to integrate the NPI numbers into the plan’s data file. We also verify the results, checking multiple data fields to ensure accuracy,” she explained.

“Our Provider360™ NPI Integrator solutions enable plans to improve processes, control costs, conserve IT and other internal resources, and achieve compliance in days, not months,” Eide continued. Because NPI is here to stay, she added, plans should start looking at implementation as a long-term investment, because it will lead to better processes and health care efficiencies in the future. In the short term, ensuring full, accurate and complete NPI data for the plan’s provider network is critical, and establishing a strategy for a full NPI transition should take immediate priority, according to Eide.

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