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Despite CMS delay, NPI compliance could cause problems

Radiology Administrator's Compliance and Reimbursement Insider, September 1, 2007

Don’t wait to participate in the process

It’s September. Spring and summer came and went. And although you meant to start that National Provider Identifier (NPI) compliance project, something always seemed to come up—such as vacuuming the swimming pool. You heaved a sigh of relief when CMS delayed NPI enforcement in May, but with the delay came an environment as unsteady as passing summer thunderstorms: CMS may decide to enforce NPI compliance at any time.

Benefit or bother

“The [May] guidance is both a blessing and a curse,” says Sally Klein, RN, MBA, PMP, project manager for FOX Systems, Inc., in Scottsdale, AZ. “It’s a blessing because it gives us more time to [implement NPI]. We all know that many providers weren’t ready. But it’s also a curse because we’re going to be in chaos for another year.”

Although CMS extended its final NPI compliance deadline—from May 23 to May 23, 2008—it reserved the right to enforce NPI on a case-by-case basis as soon as it deems enough of the industry to be compliant. And that could be at any moment. “I think there will come a moment when those who don’t have [an NPI] will have real issues,” says Alice G. Gosfield, of Alice G. Gosfield & Associates, PC, in Philadelphia. “And I think that moment is looming.”

Conditions of contingency

To be in compliance, providers must use an NPI for all transactions covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) that require an identifier. For example, if a radiologist transmits a transaction with only his or her legacy identifiers (unique provider identifier numbers [UPINs], which were used previously), or if an outpatient mammography clinic files a claim that contains both legacy identifiers and NPIs, the transaction does not comply, according to a April guidance from the Department of Health and Human Services (HHS) (www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf).

Therefore, only those currently working to implement NPIs can relax completely as the chilled air begins to close out summer. According to the HHS guidance, complaints trigger enforcement. For example, if CMS receives a grievance regarding NPI noncompliance, the agency will notify the entity in writing. The healthcare provider—be it an independent diagnostic testing facility (IDTF) or hospital outpatient MRI facility—will then have the opportunity to:

1. Demonstrate compliance

2. Document its good faith efforts to comply with the standards

3. Submit a corrective action plan

“As long as covered entities . . . continue to act in good faith to come into compliance, meaning they are working toward being able to accept and send NPIs, they may establish contingency plans to facilitate the compliance of their trading partners,” the guidance states.

In determining whether an entity made a good faith effort, CMS intends to emphasize sustained actions and demonstrable NPI implementation progress, such as:

  • The possession of an NPI and the ability to use it on HIPAA transactions
  • A provider’s increased external testing of NPI with its own healthcare partners
  • A concerted effort in advance of the May 23 initial NPI implementation deadline and continued efforts to conduct outreach and testing

    NPI decisions

    NPIs fall under two different categories—Type 1 for individual healthcare providers such as physicians and Type 2 for organizations.

    HIPAA-covered entities must obtain at least one NPI and can obtain additional NPIs for their subparts. For example, if an IDTF also includes a specialized mammography facility, it could obtain one NPI number for the facility or multiple sets of NPIs for individual units.

    To decide which option works best for your facility, look at the legal structure of your organization, says Susan A. Miller, JD, independent consultant and chief operations officer at HealthTransactions.com in Massachusetts. Miller, a member of the Southern Healthcare Regional Administrative Process, a public and private industry partnership, joined CMS in a panel discussion of NPI issues in July.

    Your facility’s approach to NPI implementation depends on its governance, corporate strategy, and business mindset. If, for example, the different branches of your radiology facility operate under different sets of senior management, or if the various entities of your company are separately incorporated or licensed, you may decide to obtain separate NPIs.

    Elements of an NPI team

    If you’re an administrator of a hospital radiology department, make your compliance officer, C-suite executives, and billing departments aware of the new NPI process. Continue to pass NPI information to the rest of your staff. Facilitate the hospital NPI compliance program throughout your department.

    Those who have not yet gathered all of the necessary personnel and plans need to start building a NPI team as soon as possible.

    Include the following groups/individuals in your NPI team as you move from legacy identifiers to the new NPI:

  • Corporate office or board of directors. Including these organizations in your NPI team is critical because they can:

    – Provide legal advice about using the NPI as you draft new policies and procedures and update old ones

    – Provide input as you refresh policies about how to enumerate authorization from physicians.

    – Help determine how staff members get providers’ permission to disseminate NPIs

    – Have the corporate office or board review governance, legal requirements, and health licensing to determine whether you should obtain one or multiple NPIs.

  • Administration. Discuss with administration strategic plans and the effect of payer contracts and affiliation agreements on the organization.
  • Billing staff. Billers need to add their depth and understanding of billing and payments, chart the changes, and oversee testing and implementation of NPI use. However, a variety of NPI-related billing errors are already being detected, according to a special Medlearn Matters article released on July 5. Most payers built a “crosswalk bypass” logic into their system to allow claim payments despite NPI/legacy inconsistencies. Nevertheless, radiology administrators need to be aware of any error messages and take corrective action to ensure proper payments once payers lift the bypass logic. Further, CMS says if you receive a reject or return-to-provider message, first double-check your data on the National Plan and Provider Enumeration System at nppes.cms.hhs.gov.
  • Admissions. These staff members collect the first level of data that directs claims and payment. Admissions staff may now need to collect additional data. Include them in workflow decisions proactively.
  • Information technology. These staff members bring their understanding of all of the technical tools and vendors to the team.

    Apply for an NPI—it’s simple

    To apply for a national provider identifier (NPI), visit the CMS Web site: https://nppes.cms.hhs.gov. You can also call 800/465-3203 to request a paper application.

    After applying, your facility will receive an NPI number and an official correspondence. Save both, because this single provider identifier replaces the different identifiers that you currently use to conduct business with your health plans.

    Get a handle on NPI history

    The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required the creation of national provider identifiers (NPI). The act attempts to standardize electronic —and, in most cases, paper—transactions, including the following:

  • Eligibility inquiries and responses
  • Claim status inquiries and responses
  • Referrals
  • Remittance advice

    The NPI is a completely random, 10-digit alphanumeric identifier. Under previous systems, identification included hidden markers that potentially indicated the geographic location, type of facility, or provider.

    The NPI affects everyone in the imaging healthcare continuum—from hospitals, to freestanding radiology facilities, to radiology group practices, to radiologists, to referring physicians.

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