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Groups recommend delay for National Provider Identifier changes
Briefings on HIPAA, April 4, 2007
The vast majority of patients encounter the healthcare system through small providers, such as one- or two-physician offices. And it turns out that these providers are most likely to be behind on getting new provider identification from the Centers for Medicare and Medicaid Services.
“The issue of subparts claimed so much time for the larger end of the environment that Health and Human Services] and the industry didn’t help the smaller end as much as they did with transactions and codes sets,” says Susan A. Miller, JD, independent consultant and chief operations officer for Healthtransactions.com, in Concord, MA. The switch to HIPAA transactions and codes sets allowed HHS to point to a universal standard. However, physicians and other providers obtain National Provider Identification numbers on an individual basis and therefore must work through their own NPI obstacles individually, Miller says.
This obstacle, as well as the fact that many providers still don’t know that they need an NPI, resulted in a February 15 letter in which the National Committee on Vital and Health Statistics called for a six-month contingency period from the May compliance date or the time CMS releases its NPI dissemination notice (if it does so after May 23). The Workgroup for Electronic Data Interchange separately called for a 12-month extension period from those same dates. Both NCVHS and WEDI are advisors to HHS.
CMS has issued more than 1.7 million NPIs, but many providers have still not applied for a number, according to a February 15 letter from NCVHS to HHS Secretary Michael O. Leavitt. Reasons include procrastination/lack of awareness, says NCVHS. And despite significant outreach efforts on behalf of CMS and in partnership with industry groups, some providers remain unaware of the need to obtain an NPI and test it with health plans prior to the compliance date. “Some providers believe themselves to be exempt because they do not do electronic billing, or they do not participate in Medicare,” says the letter. And still others, who care for underserved populations, may not bill for services.
Provider readiness varies by state, says Stephen C. Witter, vice president of Folio Associates in Hyannis, MA, who with Miller coauthored HCPro, Inc.’s HIPAA NPI Road Map: How to navigate and implement the National Provider Identifier. But even if most providers in a state have NPIs, they may not have shared them with payers. And hospitals may have NPIs for their own physicians, but not for their referring physicians, he says.
CMS’ failure to yet release a dissemination notice puts huge pressure on the agency to delay the compliance date because “the lack of free exchange of NPIs will bring the system to a standstill,” says Witter. But as far as CMS is concerned, talk of a delay “stops the wheels,” he says. That’s why both NCVHS and WEDI recommended “a contingency period,” and you will likely see CMS use that same language. The industry as a whole is hoping for some type of transition period.
NCVHS recommendations
In its February 15 letter, NCVHS, which is responsible for assisting HHS in adopting HIPAA’s administrative simplification provisions, reported its findings to HHS from January 24 testimony from associations representing providers, pharmacies, health plans, healthcare software vendors, and third-party billing companies. “All expressed a great degree of concern and agreed that many in the industry will not be able to meet the May 23 compliance date,” says the letter.
Along with the inability to achieve full enumeration, NCVHS cited the lack of access to data from the National Plan/Provider Enumeration System as a major obstacle to meeting the May compliance date. “Many plans need NPPES data to build crosswalks between legacy provider identifiers and NPIs in their own systems to ensure validation of the NPIs from providers and to ensure timely processing of transactions,” reads the letter. “In addition, providers also need to obtain the NPIs of other providers, because claims require the provision of both the primary billing provider and the ordering or referring provider. For example, pharmacies need the NPI of the prescribing physician in order to submit a valid claim.”
CMS must publish its data dissemination notice in order to release NPPES data, and delays in doing so will further impede progress toward industry compliance and health system efficiency, says NCVHS. The group also offered the following recommendations to HHS:
WEDI recommendations
Given the current state of readiness, there will be major disruptions in cash flow if CMS does not adopt and carry out a contingency plan, according to WEDI. In a February 9 letter to NCVHS Chair Simon Cohn and members Jeffrey S. Blair and Harry Reynolds, WEDI recommended a contingency period—12 months from May 23, or the date HHS makes NPPES data accessible, whichever is later.
Like NCVHS, WEDI says the industry requires the dissemination of NPPES data to achieve compliance. In an early 2006 letter to HHS, WEDI notified the department that the industry needed the dissemination notice by June 2006, but there is still yet to be an estimated date for the release of the notice from CMS. Vendors must also provide their NPI-ready products with sufficient time for installing, testing, debugging, and moving to production.
A six-month contingency period would provide “insufficient time to allow for a complete and successful implementation process, given the status of the key industry stakeholders at this point in time,” the letter states. This 12-month period will allow necessary time between the date when providers must have their NPIs and when the industry as a whole must fully comply, in order to allow dissemination, crosswalk build-up, testing, and production, says WEDI.
WEDI’s recommended contingency period requires the following conditions by May 23:
Between May 23 and six months after the “start date,” the plan would allow providers, payers, and clearinghouses to receive/send transactions with or without the NPI. But during this period, all entities must begin (or continue) and complete their testing of NPI transactions and NPI-capable systems.
Between six and 12 months after the “start date,” WEDI’s contingency plan would require providers, payers, and clearinghouses to send/receive transactions containing NPIs. They will be able to also submit or receive legacy identifiers, but always along with corresponding NPIs. Exceptions include
Twelve months from the start date, providers, payers, and clearinghouses would have to complete their full transition to the NPI and be in full compliance with the requirements.
Contingency planning
It benefits providers to be ready for NPI compliance as soon as possible. “The administrative simplification side to NPIs is significant,” says Witter. “Providers will eventually go from using various identifiers to using only one.”
You might think you’re ready now, he says. “But if you miss anything, you won’t get paid.” Take time now to do a thorough assessment of your compliance efforts, he says.
Providers and health plans that are only performing internal testing of the NPI at this point are at a disadvantage, adds Miller. “You want to be doing external testing,” she says. At this stage, you should be exchanging information with your payers to determine whether you’re supplying the NPI to the payer correctly and whether the payer can accept the NPI and process payment.
Michael Iarrobino is the editor of Briefings on HIPAA. He may be reached at miarrobino@hcpro.com. This story first appeared in the March edition of Briefings on HIPAA, a monthly newsletter by HCPro Inc. For information on all of HCPro’s products, visit www.hcmarketplace.com.
“The issue of subparts claimed so much time for the larger end of the environment that Health and Human Services] and the industry didn’t help the smaller end as much as they did with transactions and codes sets,” says Susan A. Miller, JD, independent consultant and chief operations officer for Healthtransactions.com, in Concord, MA. The switch to HIPAA transactions and codes sets allowed HHS to point to a universal standard. However, physicians and other providers obtain National Provider Identification numbers on an individual basis and therefore must work through their own NPI obstacles individually, Miller says.
This obstacle, as well as the fact that many providers still don’t know that they need an NPI, resulted in a February 15 letter in which the National Committee on Vital and Health Statistics called for a six-month contingency period from the May compliance date or the time CMS releases its NPI dissemination notice (if it does so after May 23). The Workgroup for Electronic Data Interchange separately called for a 12-month extension period from those same dates. Both NCVHS and WEDI are advisors to HHS.
CMS has issued more than 1.7 million NPIs, but many providers have still not applied for a number, according to a February 15 letter from NCVHS to HHS Secretary Michael O. Leavitt. Reasons include procrastination/lack of awareness, says NCVHS. And despite significant outreach efforts on behalf of CMS and in partnership with industry groups, some providers remain unaware of the need to obtain an NPI and test it with health plans prior to the compliance date. “Some providers believe themselves to be exempt because they do not do electronic billing, or they do not participate in Medicare,” says the letter. And still others, who care for underserved populations, may not bill for services.
Provider readiness varies by state, says Stephen C. Witter, vice president of Folio Associates in Hyannis, MA, who with Miller coauthored HCPro, Inc.’s HIPAA NPI Road Map: How to navigate and implement the National Provider Identifier. But even if most providers in a state have NPIs, they may not have shared them with payers. And hospitals may have NPIs for their own physicians, but not for their referring physicians, he says.
CMS’ failure to yet release a dissemination notice puts huge pressure on the agency to delay the compliance date because “the lack of free exchange of NPIs will bring the system to a standstill,” says Witter. But as far as CMS is concerned, talk of a delay “stops the wheels,” he says. That’s why both NCVHS and WEDI recommended “a contingency period,” and you will likely see CMS use that same language. The industry as a whole is hoping for some type of transition period.
NCVHS recommendations
In its February 15 letter, NCVHS, which is responsible for assisting HHS in adopting HIPAA’s administrative simplification provisions, reported its findings to HHS from January 24 testimony from associations representing providers, pharmacies, health plans, healthcare software vendors, and third-party billing companies. “All expressed a great degree of concern and agreed that many in the industry will not be able to meet the May 23 compliance date,” says the letter.
Along with the inability to achieve full enumeration, NCVHS cited the lack of access to data from the National Plan/Provider Enumeration System as a major obstacle to meeting the May compliance date. “Many plans need NPPES data to build crosswalks between legacy provider identifiers and NPIs in their own systems to ensure validation of the NPIs from providers and to ensure timely processing of transactions,” reads the letter. “In addition, providers also need to obtain the NPIs of other providers, because claims require the provision of both the primary billing provider and the ordering or referring provider. For example, pharmacies need the NPI of the prescribing physician in order to submit a valid claim.”
CMS must publish its data dissemination notice in order to release NPPES data, and delays in doing so will further impede progress toward industry compliance and health system efficiency, says NCVHS. The group also offered the following recommendations to HHS:
- Take the lead to provide more outreach to inform providers, especially small program and minority providers, of the need to acquire NPIs, while enlisting the participation of organizations that represent the healthcare industry.
- Decide what NPPES information it will make available to the industry, issue a data dissemination notice, and make the data available at the earliest date possible.
- Require covered providers to obtain their NPIs and health plans and clearinghouses to complete systems changes necessary to accept NPIs on HIPAA transactions by May 23.
- Publish contingency guidance that protects otherwise compliant covered entities from enforcement action if they develop and carry out contingency plans, such as continuing to accept legacy identifiers, to assure continuity of operations. This guidance should institute a six-month contingency period with the following conditions:
- If HHS issues the data dissemination notice and makes NPPES data available to the industry prior to or on May 23, the contingency period would end six months later, on November 23.
- If HHS issues the data dissemination notice and makes NPPES data available after May 23, the contingency period would end six months after the date the data are available.
- If HHS issues the data dissemination notice and makes NPPES data available to the industry prior to or on May 23, the contingency period would end six months later, on November 23.
WEDI recommendations
Given the current state of readiness, there will be major disruptions in cash flow if CMS does not adopt and carry out a contingency plan, according to WEDI. In a February 9 letter to NCVHS Chair Simon Cohn and members Jeffrey S. Blair and Harry Reynolds, WEDI recommended a contingency period—12 months from May 23, or the date HHS makes NPPES data accessible, whichever is later.
Like NCVHS, WEDI says the industry requires the dissemination of NPPES data to achieve compliance. In an early 2006 letter to HHS, WEDI notified the department that the industry needed the dissemination notice by June 2006, but there is still yet to be an estimated date for the release of the notice from CMS. Vendors must also provide their NPI-ready products with sufficient time for installing, testing, debugging, and moving to production.
A six-month contingency period would provide “insufficient time to allow for a complete and successful implementation process, given the status of the key industry stakeholders at this point in time,” the letter states. This 12-month period will allow necessary time between the date when providers must have their NPIs and when the industry as a whole must fully comply, in order to allow dissemination, crosswalk build-up, testing, and production, says WEDI.
WEDI’s recommended contingency period requires the following conditions by May 23:
- Covered providers must obtain their NPIs (this includes providers who must include an NPI on paper claims)
- Providers must communicate their NPIs to their trading partners
- Payers and clearinghouses must be ready to receive/send transactions with NPIs and legacy identifiers
- Providers, payers, and clearinghouses must begin to test transactions with NPIs and legacy identifiers
Between May 23 and six months after the “start date,” the plan would allow providers, payers, and clearinghouses to receive/send transactions with or without the NPI. But during this period, all entities must begin (or continue) and complete their testing of NPI transactions and NPI-capable systems.
Between six and 12 months after the “start date,” WEDI’s contingency plan would require providers, payers, and clearinghouses to send/receive transactions containing NPIs. They will be able to also submit or receive legacy identifiers, but always along with corresponding NPIs. Exceptions include
- pharmacy transactions
- if HIPAA or the health plan (for paper transactions) doesn’t require the secondary healthcare provider to obtain/use an NPI
- if the provider is not a healthcare provider under HIPAA and is not eligible to obtain an NPI
Twelve months from the start date, providers, payers, and clearinghouses would have to complete their full transition to the NPI and be in full compliance with the requirements.
Contingency planning
It benefits providers to be ready for NPI compliance as soon as possible. “The administrative simplification side to NPIs is significant,” says Witter. “Providers will eventually go from using various identifiers to using only one.”
You might think you’re ready now, he says. “But if you miss anything, you won’t get paid.” Take time now to do a thorough assessment of your compliance efforts, he says.
Providers and health plans that are only performing internal testing of the NPI at this point are at a disadvantage, adds Miller. “You want to be doing external testing,” she says. At this stage, you should be exchanging information with your payers to determine whether you’re supplying the NPI to the payer correctly and whether the payer can accept the NPI and process payment.
Michael Iarrobino is the editor of Briefings on HIPAA. He may be reached at miarrobino@hcpro.com. This story first appeared in the March edition of Briefings on HIPAA, a monthly newsletter by HCPro Inc. For information on all of HCPro’s products, visit www.hcmarketplace.com.
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