Uncovering Providers without NPIs
Okay, people keep telling me it doesn't matter what the regulations say. It doesn't matter what the standards say. When it comes to HIPAA rules, the only thing that matters is what Medicare -- er, CMS -- says. I keep carping on about how there are all these providers that aren't required to obtain NPIs. That they are not "covered entities" under HIPAA.
Yet Medicare seems to have coded its system to expect everybody who pokes, prods, sniffs or titrates anyone over age 65 to have one, come May 23.
How big a problem could this really be, Marty? They ask me.
So I turn it back around at them. W-e-ell, let's just see what CMS has to say about it! Let's just see how specific they got about this very topic back on September 26, 2006, shall we?
Another question. We have a group practice with ten physicians. Who gets the NPI, the group or the physicians? If the group conducts any of the HIPAA standard transactions it's a covered healthcare provider and as such must obtain an NPI. The ten physicians, on the other hand, are furnishing services at the group office or offices but they are not conducting any of the HIPAA standard transactions. The group is sending the claim. The group is checking eligibility and checking claim status, not the physicians.
If the group does these things electronically then it's a covered health care provider and must obtain an NPI. The physicians would not be covered health care providers and are not required by the NPI Final Rule to obtain NPI. But you might want to keep in mind, the group as the provider could require these physicians to obtain NPIs and use the NPIs to identify them as the rendering providers in the claims that the group submits. [CMS National Provider Identifier Roundtable Transcript, September 26, 2006, emphasis added]
That's how big a problem it could be.
Interesting scenario. We built our new product on the premise that all doctors would have an NPI by now. Plus, we cross index work done under a Provider NPI with the Facility NPI. In the case of our beta customer, they have 5 different Facility NPI's - some obviously for different addresses, but a couple are for different functions within the same hospital. So, I could see your example moved further where a claim is filed with the 'wrong' NPI by accident, whether at the provider or facility side of the equation. More chances for payors to delay payment until the numbers are validated, I guess.
Posted by: Curtis | February 21, 2008 at 12:05 AM