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.
“[W]e had a CHOW that was approved at the end of November…and those clients are still being told their NPI is not on the crosswalk. And that’s over two months later.” (Billing Service caller, CMS Roundtable call, Feb 6, 2008)
“[We finally] got the answer that in their system that the NPI number has to be correct on four different places or in four different places, three or four different places, three places it was.” (Nursing Home caller, CMS Roundtable call, Feb 6, 2008)
“But we had to literally take off the NPI, completely off the claim, had to print those claims out and this is by their instruction, print these claims out, mail them in and we’ve been waiting for our money since October and we have tried every way in the world to get some answers on this, to get paid, to get a hold of CMS, to actually get a hold of someone who cares at Palmetto GBA, we’ve contacted our local government officials, federal government officials and we’re still in the middle of this whole mess with this NPI number…[A]ll my claims…have been rejecting since October.” (Small Practice caller, CMS Roundtable call, Feb 6, 2008)
“’We have no cash flow,’ a private practice physician in Queens…said. His office manager has about 200 rejected Medicare claims on her desk.” Glitch by the U.S. Government Is Delaying Medicare Payments, NY Sun March 28, 2008
“Medicare Part B provider enrollment group has informed us that PECOS (the enrollment system) did not correctly map info from NPPES for organization NPIs. They have just now realized that they need to key in all of our organization NPIs so that PECOS has the same correct information as NPPES.” Anonymous Provider, personal correspondence, June 14, 2007
"They have us addressing the legal name which has to exactly match IRS and NPPES (even down to punctuation and spacing) and sending multiple Section 4s (Practice Location) for each of the OSCAR numbers even though they all go to the same NPI and physical address. And they swear making these changes will help the situation!" Anonymous Provider, personal correspondence, April 7, 2008
"If nothing else works, I guess we will be forced to get additional NPI. Of course that will make it so we can't bill Medicaid because they can't map multiple NPI to single legacy." Anonymous Provider, personal correspondence, April 4, 2008
Could it be true that Medicare is telling providers that they need to be ready to in just a few weeks, even when they can't commit to making the changes to their own system in a timely manner? You might have to blow this one up, since the disclosure is carried in fine print:
“Claims will reject when there is not a match on the Medicare NPI Crosswalk. You must correct any data which may be preventing an NPI/legacy match on the NPI crosswalk. The correction might require that you file a CMS-855 Medicare Provider Enrollment form with your Medicare carrier, A/B MAC, or DME MAC a process which can take a number of months to accomplish.” CMS MLN Matters Number SE0802
Remember also, that this is the EASIEST part of implementing NPI: Providers identifying themselves, updating records they control themselves (at least in theory), so that just one payer -- Medicare -- can identify them.
What happens when...
- Medicare turns on their untested NPI-for-all edits for so-called "Secondary Providers" (Referring, Ordering, Operating, etc.), currently scheduled for May 23?
- Medicaids and other Medicare cross-over payers lose the legacy ID currently being sent in dual-use mode (also scheduled to end May 23, at least per the CMS Contingency Guidance)?
- Patients begin to show up at prescription counters only to find that their dentist/psychologist/hard-to-decipher-surname prescribing doc has no NPI?
- Other payers start trying to enforce their multitudinous views of the NPI universe. These may have as little to do with either the spirit (providers define themselves, payers universally accommodate) or the letter (payers cannot force a provider to enumerate subparts, non-covered providers are exempt from the mandate) of the law as Medicare's own intransigent contingency has proven to have been.
"9-1-1, Please Hold...."
Will CMS back down? Probably, but that probably won't matter much. They've long since abandoned any pretense of enforcing HIPAA rules regarding standard transactions, so saying they won't enforce NPI does little more than reassure a handful of nervous compliance officers and corporate counselors.
Railroad Crossing, Look Out for the Cars
The problems lie in the codes of systems, not the code of regulations. Even so, we don't predict a widespread train wreck. Of course, that may be small consolation if you happen to be one of the providers, patients, or payers caught in the Crosswalk of Doom.
[NOTE: Things have turned out far worse that we predicted, but the good news is that we got a copy of the Medicare crosswalk logic. Download it here.]
Back to Our Survey
So we've put together this survey. Not how NPI should be or might be or is planned to be, but how it is, right now, playing out across the country.
Look for it. Respond to it. Help us get the word out. We'll share the results with anybody who wants them -- even those folks in the Casey Jones hats.
The reply above about matching the IRS name, including spaces and punctuation, is particularly interesting. The ANSI specs call for no punctuation in most fields; many clearinghouses and software products are helpful in stripping out the punctuation before it reaches the payer...
Well - it's all what you get when you let the fox guard the henhouse. HIPAA enforcement should never have been put in the hands of a payer.
Posted by: Steve Emery | April 10, 2008 at 08:59 AM
The IRS comparison has become a new, explicit and confounding new requirement for providers. The changes they announced last week should be hitting affected providers' mailboxes now. You can read more about this issue at http://blog.hittransition.com/2008/06/first-look-cms.html
If you want to enlist our help in fixing this and other NPI problems, we are offering a quick-and-easy method for a limited time. See http://blog.hittransition.com/2008/06/we-will-help-yo.html
Posted by: Martin Jensen | June 16, 2008 at 11:44 AM