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Overcome NPI billing and compliance obstacles

Radiology Administrator's Compliance and Reimbursement Insider, March 1, 2006

Be on the lookout for two of the most problematic areas facing your organization's transition from legacy identification (ID) to national provider identifiers (NPI) that are also at the heart of your bottom line and legal concerns: billing and compliance.

To overcome the obstacles NPIs pose in these areas, negotiate with your payers or providers early in the process, said Chris Apgar, CISSP, president of Apgar & Associates, LLC, in Portland, OR, who spoke about this topic during the November 15, 2005, HCPro audioconference "National Provider Identifier: Know how changes will affect your business." (Visit www.hcmarketplace.com for more information or to order.)

NPIs offer business benefits (e.g., the portability to go with you when you move beyond state lines). But expect some headaches because NPIs differ fundamentally from legacy IDs. One particular hardship stems from the struggle to replace the logical information embedded in legacy ID.

"[Many] legacy IDs have identifiers within the number that say, 'Okay, this was issued to this provider, who is in this city, doing this type of practice,' " Apgar explained.

NPIs do not contain this information. Instead, to pay and be paid properly for services, providers and payers must find a place for this lost information somewhere on their claims forms.

Conduct an analysis, replace what is lost

A sole NPI cannot communicate different payment rates by treatment location, multiple contracts with the same provider at different rates of payment, and differentials within a provider group based on specialty.

Account for these situations by using an NPI as the core of a smooth business transition. To start this process, Apgar suggests taking stock of your current billing process.

Analyze how you use your legacy ID to convey information. For example, the ID may tell your payers that you bill from a certain location and at a different pay rate from other locations. Obtain input for this analysis from your information technology staff, those involved in switching your organization over to HIPAA transactions, and people within the claims processing or billing departments, Apgar said.

After you determine your legacy ID's role in the billing process—and what you'll lose as a result of the switch to NPI—consider alternative ways of communicating location, contract, and specialty information to payers. Apgar suggested the following two alternative avenues:

1. Multiple NPIs. "There's no specific guidance on how to determine what is necessary in the way of more than one NPI, but you do need to obtain more than one if you're a large organization so you can make sure you're being billed correctly," he said.

Consider obtaining subpart NPIs to differentiate between treatment locations or specialties within the same organization, depending on with what your payment rates correlate.

However, an organization with multiple NPIs has no easy way to show that all of the NPIs relate to the same organization because each NPI is location-specific. This can create problems for payers conducting research.

2. Space on the claims form. This could include the comments field or lie at the claim-line level. The addition of a street address, ZIP code, or other relevant information in these areas may help to ensure that you are paid properly.

Regardless of which solution you choose, negotiate it with your payer. The payer must understand how you identify your organization and the relevant information. If you add information at the claim-line level, your payer needs to know.

As part of the negotiations, address the following:

  • Dual reporting during implementation. Dual reporting means using both legacy ID and an NPI during the transition period to ensure that you send enough information to be paid correctly.

    "[The transition] is a long process, and the earlier you can get started on actually obtaining an NPI and testing that with your payers, the better," said Apgar.

  • Secondary identifier needs. NPIs may only get you so far, and they do not take the place of other important IDs (e.g., your taxpayer ID number), Apgar said.

    Look at what you need from the NPI and what you need from secondary identifiers to accurately reflect the services provided and receive correct payments, he explained.

  • Paper claims. The NPI mandate does not extend to paper claims, but from an administrative standpoint, you may be better off making the switch now to standardize everything, Apgar said. Although forms such as the UB-92 and CMS 1500 cannot currently accommodate an NPI, CMS may soon make room for the new identifier.

    Bring vendors up to speed

    Equally important to being paid properly is complying with the NPI mandate in the first place. Unfortunately, compliance may be more difficult to tackle, especially regarding vendors that must make sure that their products can transmit and receive NPIs.

    Although providers and payers both have a vested interest in making sure a particular service is reimbursed correctly, vendors have no direct stake in NPI transition.

    "Vendors are not HIPAA [Health Insurance Portability and Accountability Act of 1996] covered entities and are not necessarily engaged," said Apgar. "One of the biggest lessons we learned rolling out [the initial HIPAA transactions] is that the vendors were lagging behind and in fact still are lagging behind in some areas."

    Because vendors may be out of the loop, let them know what you need. It may come down to saying, "If your software can't use NPI, we can't do business with you," Apgar said.

    Allow enough lead time for the vendor to address problems before you make the permanent NPI switch.

    Editor's note: This article first appeared in Health Information Compliance Insider , published by HCPro, Inc.

    Insider source

    Chris Apgar, CISSP, president, Apgar & Associates, LLC, 10730 SW 62nd Place, Portland, OR 97219, 503/977-9432; capgar@easystreet.com.

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