The HIT Transition Weblog

Prepping for CCS

Last fall, I reported about how much fun I had at the Collaborative Communications Summit. Not "fun" as in golf outings and spa appointments, but "fun" as in meeting some really interesting and influential people, and being surprised at just how much some executives at the top tiers of the healthcare industry actually know about health IT. But CCS is not just about IT, it's about IT-enabled healthcare, which is a different spin from the typically techy-wonky conferences I traditionally attend.

And I didn't just like it enough to go back; I liked it enough to help make the next one happen. [Disclosure: HITTG is a media sponsor for this event. But we don't sell blog endorsements to anybody.]

Multisyllabic Session Title #1
On Tuesday, I'll be moderating a session called, "Unified Vision with the Consumer and Provider through HIT." I've got an incredibly qualified -- and incredibly broad -- array of panelists:

• Carolyn M. Clancy, MD, Director, Agency for Healthcare Research & Quality
• Michael E. Singer, President, Revolution Health Investments, Revolution Health Group
• George Chedraoui, Global Well-being & Health Benefits Leader, IBM
• Grad Conn, Senior Director, Health Solutions Group, Microsoft Corporation

And before you jump to any conclusions, no this is not a PHR vs. PHR smackdown with a government referee. First, you should note that Mr. Chedraoui has a largely HR perspective -- he's on the boards of both the Leapfrog Group and Bridges to Excellence, recently serving a term as the latter organization's chair. So he's bringing IBM-as-employer mojo, not just IBM-as-programmer-to-the-world. And I don't expect Conn is showing up just to shill for HealthVault, since Microsoft's entire health sector -- personal and enterprise -- reports to him.  Singer has a doctorate from the London School of Economics, which means I will probably buttonhole him first and ask if he's ever met Mick Jagger. I think he's working on some sort of portal these days. Singer, that is.

Taking the Moderation out of "Moderator?"
And, just to make sure the conversation is lively, I've given them all a daunting task.

"Engage me."

As a tough-but-interested, enthusiastic-but-skeptical, chronic-conditioned-but-disclosure-averse patient with a checkbook, I could be your best -- or worst -- customer. 

Engage me.

(And yes, I will be nice. I promise. After I set up the challenge.)

Multisyllabic Session Title #2
As if that isn't enough fun, I get to host the second day's "High Performance Leadership" session. This is the slot made famous by last year's CEO roundtable, where athenahealth's Jonathan Bush, Allscripts President Lee Shapiro, Andrew Eckert, CEO of Eclipsys, and Jeff McCaulley, CEO of Wolters Kluwer Health made such an impression on me, I wrote it up as a TV pilot, which was eventually re-cast and optioned as an animated short for the HIMSS conference.

Can we outdo that august assemblage this year? Looks like we'll give it a run. Here's our roster.

• Duncan James, Group President, Health Systems Market, McKesson Provider Technologies
• Oran Muduroglu , CEO, Healthcare Informatics, Philips Healthcare
• Graham Hughes, MD, GM of Product Strategy, GE Healthcare IITS

Like last year, it will be short prepared statements (keep your PowerPoints in their holsters, please, gentlemen!),  followed by a lively Q&A from the assembled C-suiters and opinion leaders in attendance. Last year, the atmosphere by the end of the second day was both congenial and charged with energy. There weren't any yawners or whiners in the group, and you could actually see ideas being connected by people who were very much able to take the next step and make something happen.

Why Wait Until Nomination Time? Let's Get Partisan!
Oh, and if that wasn't enough, the organizers have got healthcare policy advisors for all three presidential candidates to agree to show up at the same time for a pleasant little chit-chat.  I thought they were really reaching when they said they would set aside time for such a forum, but they pulled it off. I guess you'd have to call that a coup.

Just got the lineup today, so it might not be posted on their website yet.

• Tom Miller, Healthcare Policy Advisor Senator McCain
• Chris Jennings, Healthcare Policy Advisor, Senator Clinton
• Dora Hughes, Legislative Assistant Senator Obama

They were too smart to put me in with that crowd. Instead, eHealth Initiative's Janet Marchibroda will get to wear the zebra suit and blow the whistle if they get out of hand. Janet's much more diplomatic than I am, so I think they'll play nice. I'd hate for her to have to pull out a Yellow Card.

But Seriously
I probably said "fun" too many times to say, now, that it would be a wise investment of your time and energies to roll up for a conference that's barely a week away. But if you're in the DC area -- or are looking for a good excuse to be in the DC area -- you might want to check it out. Monday and Tuesday, May 5 and 6 at the Mandarin Oriental.

Retraction: FAQ 5816 Found

I couldn't handle it. I hate leaving uncited references in my blog posts. I finally dug around through my own materials and found some text I had copied from CMS FAQ 5816 back in 2006 -- the one I referenced in today's earlier blog.

I was wrong -- so wrong -- that 5816 said you couldn't use non-NPI identifiers in NCPDP pharmacy transactions. Here it is, plain as day:

If a covered entity needs to identify a noncovered health care provider who does not have an NPI in a standard transaction, the noncovered health care provider:

• Must be identified by its SSN or EIN as its Primary Identifier in standard transactions designed to capture a Primary and a Secondary Identifier for a health care provider….
• Must be identified by one of the qualifiers (other than the qualifier for the NPI) listed in the Implementation Guides for the standard transactions that are designed to capture a single identifier for a health care provider.

Geez, talk about having egg on my face. There they were, telling the entire industry exactly how to accommodate for the unenumerated provider, and I thought they hadn't accounted for exceptions.

You Never Hear the One That Gets You
That's in bullet two, by the way. I remember, now, because I had to ask whether the second bullet was for all those X12 transactions that allow you to send just a secondary ID (like a UPIN, a Medicaid ID, a BCBS number, etc.) if no primary ID is available. They said no, silly, that's about the NCPDP transaction, where there is only one provider ID segment available. Bullet one is for X12; Bullet two is for NCPDP.

I completely forgot about that email.

My Bad
So I guess I should take all that stuff back about CMS not allowing for reality. On the X12 transactions, just send the Social Security Number if you don't have the NPI. Unless it's illegal. Or, of course, if the doctor who won't obtain an NPI won't give you his SSN either.

Or, unless you're billing Medicare, which, it turns out didn't read CMS FAQ 5816 when they said to send your own NPI in place of the Referring, Attending, Ordering, etc., when he/she/it didn't have an NPI. Wrong again, Marty!

Or, wait, now that they took 5816 down, I guess we can't assume that it's okay to do that, either. And I guess the people who built their systems around all the implementation details 5816 contained -- the ones that weren't in the NPI Final Rule or the X12 Implementation Guides -- better get ready to make some changes.

Don't worry. You've got until May 23. Let's keep looking for those new instructions. I'll let you know if I see them first.

CMS: Don't Strand Patients at the Prescription Counter for NPI

In a belated and much understated concession to reality, CMS just posted an FAQ that acknowledges that not all prescribers will have NPIs, and that payers who require an identifier can allow pharmacies to use another number.

In the rare cases when either a prescriber does not have an NPI or the pharmacy cannot obtain an NPI, and where the prescriber ID is required by the payer, non-NPI individual identifiers may be substituted if allowed by the payer.

The Opposite of Well Done
How "rare" will such cases be? Well, in the case of all of the retired, academic, dental, mental health, privacy-obsessed and regulation-averse practitioners around the country who didn't obtain an NPI -- or just the ones that believed CMS when it said if they didn't touch the keyboard to send the transaction, they weren't a covered entity -- it will be every prescription they write.

And for their patients, it will be every prescription they try to fill, month after month. I guess "rare" depends a lot on your point of view -- whether you're counting percentage points in tens of millions of claims or counting the pills left in your bottle.

Will this be enough to keep patients around the country from being stranded at the prescription counter on Memorial Day weekend? No -- but a lot of payers already understood the problem before CMS posted FAQ 9100.

"We few, we happy few, we band of brothers."
Instead, the problem, as always with such late-stage shifts of policy, will not be with the many payers and vendors who understood what CMS was steadfastly refusing to admit, but with the few that drank CMS's many previous batches of oversweetened regulatory kool-aid unquestioningly, and built systems based on wishful thinking.

Little outfits like, say, Medicare Fee-for-Service.

Simple One-Number Interface!
Also, we've heard of prescribing POS systems that can only send one kind of identifier -- NPI or State License or Whatever -- to all payers for all patients. Seems ridiculous, but any pharmacy that's facing a transition like this will also face long lines of angry customers until they force their vendor to change or change their vendor by force.

I Loved You in that Hamburger Movie
Another new challenge came up on a call the other day -- the foreign born doc that uses an anglicized name in his practice, but is listed in NPPES by his unpronounceable (in Americanese, at least) legal given name in NPPES. Do you think the NPI Registry's clever name synonymizer can equate "Atulkumar" with "Al" or "Art?"

These are the real problems that we would face anyway. The one that CMS has created with its blinkered guidance up to the last possible minute is a manufactured and unnecessary one.

Historical Perspective
So how "last possible" is this minute? Yesterday's publication date is 30 days before the end of the contingency period announced at just about this time last year. But looking backward, it's 336 days after the original NPI implementation date; 4 years, 4 months after the publication of the NPI Final Rule established broad implementation directives for Covered Entities (decidedly not "All US Healthcare Providers"); 7 years, 9 months, 6 days after the HIPAA Transactions and Code Sets Final Rule defined "Covered Entity" as a subset of providers, and 9 years, 9 months, 26  days after the original System of Records notice called for an enumeration system that would apply to "every health care provider that transacts electronically," with Medicare and Medicaid providers (regardless of electronification) thrown in for good measure.

The Disappearing NPI Policy?
But as late as this notice may, in such retrospect, seem, it is not the final word. No, in fact, we are still awaiting such evidence-based regulatory guidance on the medical side of the claims equation. We should, perhaps, take it as a positive sign that the misguidance previously published, the notorious FAQ 5816, seems to have mysteriously disappeared from view on the CMS website. [Click here to see if it's come back]. 5816 was the one that told you what to do to resolve the differences between the instructions in the X12 implementation guides, which seemed to allow for mulitple identifiers, and the NPI Final Rule which, according to CMS at least, only allowed for NPI.

This is what I've previously referred to as the basis for the NPI Über Alles Manifesto. No legacy numbers, period. Maybe an EIN or SSN (which, by the way, is illegal in many states). 5816 and Medicare's onerous implementation plan put the onus on providers to get the recalcitrant members its community to enumerate.

NPI Means Whatever We Want It To Mean
That's the policy that Medicare's FFS system designers seem to have been following when they decided to put a hard edit in place to deny claims that didn't have an NPI in every slot. And later, their reluctant nod to reality was not to redefine their edits, but to redefine Referring Provider and all the other fields where a non-enumerated practitioner may need to be represented.

"Just send your own NPI if they don't have one" was their "fix" to this problem.

And as of right now, it still is, for a million Medicare FFS providers.

Are you ready for that on May 23?

Enrollments are still open for our NPI Webinars next week.  The first video, NPI: Facts In Evidence will be ready tomorrow, or perhaps even later today [UPDATE: "Later today" it is -- see add link below]. There's still time to take our NPI Contingency Status Survey before midnight tonight. Free results to be distributed next week also.

NUBC Calls for NPI Delay

The National Uniform Billing Committee has sent a letter to HHS Secretary Michael Leavitt asking for an extension of the Dual Use period, which would allow providers to continue to send both NPI and legacy identifiers for an additional six months.

Waiter? There's a Fly on Your Face
The letter specifically takes CMS's Medicare department to task for actions that "fly in the face of the original intent of the NPI Final Rule."

Which is a polite way of saying that, by telling Providers to get NPIs for each of their legacy Medicare IDs, Medicare contractors and CMS itself (via a stream of communications over the past several years) is violating its own regulations.

The appropriate response, according to NUBC is an extension of the contingency.

We believe a six month extension for dual identifier reporting is needed to allow all trading partners to complete the work necessary to ensure accurate mapping of NPI to legacy numbers and ensure that the Medicare certification process -- including all interfaces to Medicare's Provider Enrollment Chain and Ownership System (PECOS) -- can be updated in a timely manner.

Contingency vs. Coherence
Like I've said before, the issue isn't compliance, it's cash flow. We don't need more contingency so much as a more coherent policy. One that's based on sound pragmatic principles (no, not all providers will have NPIs, and edits that insist upon them will stall claims and penalize providers), adherence to the letter of the regulation (providers get to define themselves, period -- deal with it), anticipation of the problems that will be created if fundamental principles are not adhered to now (providers will need to identify themselves to all payers in the same way, or everything will get worse instead of better) and a truly sensible set of incentives for all (organizations who flout the law will get punished -- at least a public accounting, and perhaps even a nominal fee, please; organizations who attempt to implement in good faith will NOT be punished for it, as so many providers attempting to send NPI-based claims through Medicare's rats nest of a crosswalk have been).

Throwing a Giant Banana to the Gorilla
Delaying enforcement of the rule for six months doesn't mean anything to anyone but Medicare. And so it is, in fact, a necessity. Several Medicaid plans have already faced reality and admitted they will not attempt to enforce strict compliance on May 23 and thus put their patients at risk. Medicare has to pretend they are complying with their own vague, unsubstantiated and often self-contradictory guidance, but they, too, don't want to tick off millions of senior citizens in an election year.

So expect the contingency to be extended, for what that's worth. A few tens of millions of dollars a month in Medicare payments that won't be disrupted is a good thing, I guess, but if we don't fix the fundamental flaws in NPI implementation -- again -- and use the excuse of contingency to push NPI to the back burner, it will again be a really bad mistake. Hopefully the existing and ongoing Medicare payment disruptions will be enough to help providers stay focused.

I trust this won't be the last we hear from NUBC on this issue. This is a necessary step, but not a sufficient one.

NPI Survey to Remain Open

Due to some late requests and our ability to bounce some priorities around, we've decided to extend the collection period for our NPI Survey to this Thursday, midnight Eastern Time.

To take the survey, or to request a free copy of the results, go to http://surveys.hittransition.com/npi . Please note that taking the survey does not automatically sign you up to receive the distribution of the results.

We'll be holding our NPI webinars tomorrow and Wednesday (NPI Facts In Evidence and NPI: Medicare Insights), but the Thursday session on the survey itself has been rescheduled to May 1. For information on all three webinars, see NPI Crunch Mode.

CMS: Providers Should Complain; Payers, Comply

Just got off the CMS NPI Roundtable call. Too much to cover in this quick note, but there were a few themes that kept coming back:

• Payers should not be telling providers how to enumerate (like saying they won't get paid if they don't get NPI numbers for each of their legacy IDs). If they do, that "appears to be inconsistent with the NPI Final Rule." Several of these seem to be Medicare contractors. CMS representatives asked for their names and promised to follow up.
• When a provider is told by a payer to do something like this (or any other non-compliant information, like continuing to send legacy IDs "forever"), they should file a formal complaint with CMS. (See How to Complain for helpful information and a link to the website). They can't initiate an investigation based on anectdotal evidence.
• The deadline for the end of contingency is May 23, 2008. Medicare representatives on the call reasserted their plans to reject claims that include non-NPI identifiers on that date, even in the case of the "secondary provider" loops, which include Referring, Ordering, Servicing, etc. (everything but Billing, Pay-to and Rendering). According to a representative from the regulatory side of CMS (paraphrasing): The rule says you will use NPI only. That is the policy. What other plans are doing won't be known to us.
• Medicare providers, even though they can't see the data in their own PECOS registration record, were repeatedly told that the answer to their problems may be to submit a new 855 Medicare Enrollment form -- and make sure you get everything exactly right! Those forms take days or weeks for providers to collect, correct, approve and submit. Then they may sit untouched for months at the carrier's site, waiting for someone to do the data entry into PECOS. That's the cure for your May 23 ills, though! Good thing providers won't object to waiting for their Medicare checks.

We Do It All For You
Speaking of Medicare FFS, they disclosed more about the crosswalk than ever before, but it was just a long list of fields that might be looked at for each type of claim. I got most of them, but not all. Will try to get the complete list for our NPI Medicare Insights webinar next week.  Even if I have to go back and listen to the whole 90 minute session again.

I've already got lots of intelligence on the crosswalk snafu, much of which would not be repeated on an official CMS call. Whether and why the crosswalk is failing, and what to do about it, will be a focus of the material on that webinar.

Survey Says
Oh, and if you want to tell the story about how your own NPI transition is going, there's still a couple days left to submit a response to our NPI Contingency Status survey. Results should be out as early as next week. There's plenty of opportunities to list your complaints there, and we'll keep your identity secret so no one can hold it against you. Of course, maybe everything is just dandy for you. If so, we want to hear that, too.

NPI Survey: Can We Assess Readiness Before It's Too Late?

The industry seems to be sliding obliviously into yet another regulatory deadline: The NPI Contingency period officially expires May 23. Which means what, exactly?

Let me tell you what it doesn't mean, in my humble and entirely non-legal opinion:

• It doesn't mean that the HIPAA Police are going to suddenly rush out of the donut shop and start issuing fines or slapping the cuffs on doctors or CEOs.
• It doesn't mean that Medicare or most any other payer is suddenly going to mandate a level of compliance that three years of remediation hasn't created in the test bed, much less in the real world. (Well, Medicare might.)

Before You Put Your Head Back Under the Sand
Unfortunately, it doesn't mean you're off the hook either.  If you're a provider, you could easily become the next victim of a payer crosswalk failure, like the ones that are leaving certain Medicare billers unpaid for months. If you're a payer, you may be drawn deeper into the vortex of inconsistent and unjustifiable interpretations of the NPI Final Rule that your industry peers may be applying -- not via provider newsletters, but via hard-coded edits -- some of which may make it impossible for certain providers to satisfy your own requirements.

So, before CMS issues yet another clarification of what May 23 really means, let me suggest a mantra that will help you get through the months ahead: It's not about compliance, it's about revenue. Ignorance may or may not be an excuse, but it's pretty hard to cash at most banks.

It Could Be Raining
How bad is it? We have our suspicions, but nobody knows. People at CMS, of course, probably know a lot more about how bad it is inside Medicare than they're letting on, but nobody really knows how it's impacting providers, other payers and the clearinghouses that connect them.

How Fast Can HITTG Do A Survey?
That's why we decided, early last week, to do a survey to find out how bad it is (or isn't).  We dropped all our other wonderful priorities and hammered out a pretty impressive instrument, if we do say so.  It focuses on what is really happening, not on what folks "plan" to do. It focuses on some particular problems we've seen emerge and go unresolved for months (years, actually). Things like providers who don't have NPIs, payer crosswalks that don't close all the gaps, and a general unwillingness to appreciate the fact that the NPI regs and standards are designed to get providers out of the business of meeting arbitrary, inconsistent and undocumented payer identification requirements.

SECRET INDUSTRY TIP: Providers are not responsible for routing claims around inside the walls of health plans.

Is it too late? We really don't think so.  Here's why:

• NPI problems will not go away on May 23, with or without a "re-contingency" notification from Medicare.
• The problems we are seeing will cause a dramatic spike in payment disruptions, if current plans are carried forward. If we are correct, the survey results will help prove it. If we are wrong, the survey results will disprove it and we can move on to something else.
• Payers may acknowledge only a "few" problems, but if you are one of the providers affected, those few can include, quite literally, 100% of your payments from that payer.
• Policymakers and remediators do not seem to be suffering from an excess of useful information.

It's Fast, It's Free, It's Frightening
That's why we're doing the survey. That's why we have such a short timeframe (collection ends on Saturday, April 19). That's why we're releasing the results to anyone who asks, within days, not weeks or months. That's why we're putting together short, low-cost webinars [link] to help people make it through May 23 and beyond.

Please take the survey. And please help us spread the word.

Mapping Medicare's Crosswalk Morass

I'm trying to put together the bullet points to explain why we've decided to launch a last-minute NPI Status survey. The gist of it is that a lot of bad decisions are being coded into payer edits, the most visible being Medicare's own NPI crosswalks. Everyone is probably banking on CMS issuing a new "re-contingency" clarification before the expiration of the May 23, 2008 deadline they announced last spring. The problem is that even with the "baby steps" Medicare has rolled out since last May, a lot of providers are already caught in a Catch-22 between conflicting payer capabilities, obscure and hyper-sensitive crosswalk edits, and write-and-wait bureaucratic red tape.

I wanted to let the providers speak for themselves, but I couldn't edit the mess down to the bullet points I needed for the survey announcement. So here's the ugly truth in providers' own words.