[Disclaimer: You probably don't want to read this. It's dry and boring. I dozed off twice while writing it. It may not even be all that accurate. Plus, you can get the same information from this CMS FAQ.
But they say that the best way to learn is to teach. So, as I struggle to understand how we got into the mess that we're in with NPIs, perhaps the best thing I can do is to try to explain it here.
So, go ahead and read if you like...but don't say I didn't warn you...]
What is the NPI?
The NPI (National Provider Identifier) is a 10-digit number used to identify healthcare providers. (A "healthcare provider"can be an individual person, as in the case of a physician or nurse; or a group of individuals that submit claims to certain insurance carriers as a single business entity.)
The NPI was mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). (Standard unique identifiers are required for both healthcare providers and health plans, but the identifiers for health plans have not yet been implemented.)
What does the NPI replace?
Historically, different insurance carriers have used a variety of different numbers to identify providers. Medicare, for example, used to issue its own proprietary identifiers (PIN, UPIN, OSCAR, NSC). Many Medicaid payers and most commercial payers expected the provider's EIN (Employer Identification Number, also known as Federal Tax ID). Still others required the provider's Social Security Number.
To further complicate the issue, some payers may require multiple identifiers. Others may give providers a choice of enrolling under, say, their EIN or their SSN.
What problems is the NPI supposed to solve?
All of the healthcare providers and insurance carriers in the United States are part of one ecosystem, with many millions of paper and electronic transactions taking place between the various parties every day. It shouldn't be a surprise to anyone that multiple provider identifiers would cause confusion and inefficiency.
One example: Primary claims submitted to Medicare, after being adjudicated by Medicare, are automatically forwarded on to the secondary payer (if there is one). Medicare can use the PIN to identify the provider, but the provider's Medicare PIN means nothing to, say, Medicaid or Aetna. So, in order for the claim to be forwarded to and paid by the secondary payer, the provider must include the EIN...or SSN...or the secondary payer's propietary identifier...or whatever, on the claim.
The NPI only addresses these issues if all providers and carriers switch from whatever identifiers they used in the past to the NPI. Consequently, all HIPAA covered entities (providers, payers, and clearinghouses) will be required to switch.
Who issues NPIs to providers?
The Centers for Medicare and Medicaid Service (CMS) issues NPIs using the National Plan and Provider Enumeration System (NPPES). (NPPES can also be used to look up NPIs.)
Can a single physician or other provider have more than one NPI?
Allowing a single healthcare provider to have more than a single NPI would violate the HIPAA requirement that NPIs uniquely identify a single provider. But this is healthcare we're talking about, so I wouldn't be surprised if it happens.
So, once a provider has an NPI, how do payers find out what it is?
As part of CMS's planning for the NPI transition, they conceived the notion of a "crosswalk" (a commonly-used term in healthcare that has been overloaded for this purpose). Basically, payers are expected to accept both their legacy identifiers and the NPI for a period of time, during which they are supposed to "crosswalk" the identifiers and associate the NPI with the corresponding providers.
On May 23, 2008, this crosswalk period officially ends, and all payers are supposed to accept claims with only the NPI. Of course, again, this is healthcare, so some payers (and we don't know how many) will fail to meet that deadline, or their systems will be so whacked that they will continue to reject claims until they can get their software fixed.
Showing posts with label standards. Show all posts
Showing posts with label standards. Show all posts
Wednesday, May 14, 2008
Friday, April 25, 2008
Why does EDI have to be so hard? (Or, "Healthcare EDI is a freak show!"*)
Okay, let me be the first to ask:
Why are EDI transactions always so difficult???
I just finished watching a DVD that was produced by Healthcare IT Transition Group, whose stated mission is (in part) "to reduce the cost and improve the quality of healthcare through the development and implementation of robust IT standards." A worthy cause, by any standards...unless you're a healthcare insurance vendor. The video is called "Defeating the Denial Engine", and it describes new tools that enterprising vendors have created and are selling to payers to help them reject more claims and, consequently, pay out less money.
Here's the idea: This new class of software allows a payer to dial up the percentage of claims that are denied, using a huge array of rules that can, to varying degrees, be reasonably justified as valid rejection reasons. If the payer sets the dial too high, resulting in a flood of complaints from providers, then they can dial it down a bit until the protests become manageable.
That's a complicated way of saying, "Insurance companies will make it as difficult as possible for a caregiver to get paid...without dramatically reducing the number of providers that are willing to contract with them."
For those of us whose mission it is to help our customers get paid by insurance companies, it means that we need to redouble our efforts to understand exactly what it takes to successfully submit a claim to every payer in the nation, and abstract as much of that away from our customers as possible.
I foresee a world where all a biller has to do is ensure that patient encounters are coded correctly (according to the common best practices of the specialty for which he is billing), and the billing software (presumably AdvancedMD for smart billers) will address all of the carrier-specific idiosyncrasies automatically, behind the scenes.
AdvancedMD certainly goes a long way towards that utopian vision--perhaps further than any of our competitors, if you believe what our customers say--but we still have a long way to go. We are actually doing some pretty exciting work right now to take us even further down the road, which I'll write about as we get closer to release.
*The association of the word "freak show" with healthcare EDI was originally made by Steve Lewis, our own EDI guru, also known as "Morpheus".
Why are EDI transactions always so difficult???
- Why is it that we always have to put quotes around the words "healthcare EDI standards"?
- Why is it that we have to conform with absolute precision to a each of a variety of specs for outgoing transactions (270, 837, etc.), but payers can send us whatever crap they want (particularly in 835 remittance files), and we have to adjust our systems to interpret them?
- Why is it that we can't send test claim files to payers to ensure that we're meeting their wacky specs? Why do we have to wait until one of our customer actually sends a claim to the payer before we can know with any certainty that our claim generation system works?
- Why can't Medicare and Medicaid intermediaries be forced to comply with HIPAA transaction standards?
- Why can't state payers (primarily Medicare, Medicaid, and the Blues) conform to their own standards?
I just finished watching a DVD that was produced by Healthcare IT Transition Group, whose stated mission is (in part) "to reduce the cost and improve the quality of healthcare through the development and implementation of robust IT standards." A worthy cause, by any standards...unless you're a healthcare insurance vendor. The video is called "Defeating the Denial Engine", and it describes new tools that enterprising vendors have created and are selling to payers to help them reject more claims and, consequently, pay out less money.
Here's the idea: This new class of software allows a payer to dial up the percentage of claims that are denied, using a huge array of rules that can, to varying degrees, be reasonably justified as valid rejection reasons. If the payer sets the dial too high, resulting in a flood of complaints from providers, then they can dial it down a bit until the protests become manageable.
That's a complicated way of saying, "Insurance companies will make it as difficult as possible for a caregiver to get paid...without dramatically reducing the number of providers that are willing to contract with them."
For those of us whose mission it is to help our customers get paid by insurance companies, it means that we need to redouble our efforts to understand exactly what it takes to successfully submit a claim to every payer in the nation, and abstract as much of that away from our customers as possible.
I foresee a world where all a biller has to do is ensure that patient encounters are coded correctly (according to the common best practices of the specialty for which he is billing), and the billing software (presumably AdvancedMD for smart billers) will address all of the carrier-specific idiosyncrasies automatically, behind the scenes.
AdvancedMD certainly goes a long way towards that utopian vision--perhaps further than any of our competitors, if you believe what our customers say--but we still have a long way to go. We are actually doing some pretty exciting work right now to take us even further down the road, which I'll write about as we get closer to release.
*The association of the word "freak show" with healthcare EDI was originally made by Steve Lewis, our own EDI guru, also known as "Morpheus".
Subscribe to:
Comments (Atom)