The HIT Transition Weblog

New HIPAA Standards Clear Regulatory Hurdle, Approach Flaming Commentary Hoops

Tired of the ambiguities and outdated constraints of the electronic claim, remittance advice, eligibility and other X12 transactions? Help is on the way.  Or at least it's coming into view.

The enabling regulation to adopt a new version of those standards has cleared the Department of Health and Human Services and has been passed on to Office of Management and Budget for final review. OMB has 30 days [OOPS! Meant to verify this before posting. In truth the rule of thumb is 90 days for the review; insiders say it is on a fast track, though. -Ed.] to approve it (with or without revisions negotiated with HHS) or reject it.

I was fortunate to have the opportunity to participate in some of the X12 workgroups that built the new standards, and am certain that the new standards will improve efficiency and reduce the number of customizations and workarounds.   We won't be able to say goodbye to those nasty Companion Guides, but at least they will be thinner.

Besides reducing ambiguity in hundreds of passages -- saying when NOT to send data as well as when to send it, for example -- the updates incorporate a number of issues currently vexing implementers:

• Unambiguous instructions for consistent implementation of National Provider Identifier submissions across all transactions and all payers.
• Intrinsic support for the Present on Admission data, rather than the K3 stopgap introduced last year.
• Support for the ICD-10 codeset, not available in the current 4010A1 standards.
• Better, clearer remittance advice instructions and standards, including mandatory utilization of the Remark Codes segment.

The standards were developed over a period of months and published back in 2004 and 2005. First the draft guides were released for public comment, then the workgroups responded to each of comments and finalized the implementation guides (now referred to as "Technical Report 3's" or TR3's) and submitted them for approval via X12's consensus process.

It has taken three years for HHS to put together the regulatory language to adopt them.

And once that draft regulation is released will come another comment period.

Um, what was that?

X12 is anxious about this. Tagging a regulatory comment period on to the standards development comment period brings a lot of new participants out of the woodwork. While techically this may improve the end result, it also stands to send the standards folks back to their own review/comment/edit process, further delaying implementation.

Last time this happened, it was under the deadline for adoption of the original HIPAA standards -- the finished 4010 guides got hurriedly updated with the A1 Addendas, and the industry has had to work out of two sets of books ever since. (I recommend purchasing the Combined Guides for those who have difficulty reading out of two volumes at once. They're not "official" but they will keep you from making a lot of errors or at least getting a lot of headaches. Go to www.wpc-edi.com and check out the HIPAA link.)

I haven't been able to participate in X12 for awhile, but I know they are all over this. I hope that some of their collaboration with the regulators produces both better standards and better adoption processes.  We soon shall see.

NPI+Taxonomy = Crosswalk or Chaos?

Are you a provider having trouble meeting the Provider Taxonomy requirements of one -- or several -- of your payers?

Are you a payer learning the hard way that the Taxonomies you ask for and the ones you actually get are many miles apart?

If it's any consolation, you're not alone. But now, there's hope....

We Will Help You With NPI Crosswalk Problems

If you came here looking for free information about your NPI problems, you will find lots of it. Click here for more than 125 articles we've posted on the subject in the last three years.

We'd like to help you more directly, if we can.  For the past few weeks, we worked on a concept to develop a "Crosswalk Coach" service that we could streamline and offer at a bargain-basement price to help the small clinics and others who were looking at years and months of Medicare denials. We even drew up a clever superhero character to represent the guy who would get you safely across the street.

No Cookie Cutter
We had to abandon the concept. There are no cookie cutter approaches to this problem. We've learned that some providers are simply in a catch-22 situation, where solving one payer's problem only creates problems for others. We can help solve some of those problems, but not necessarily all of them. You may be experiencing an issue that can be fixed quickly, and we hope you do. But we simply can't guarantee anyone safe passage, as much as we'd like to.

So, in our forthright sort of way, we will offer instead...

Medicare's Wrong... No Willy Nilly NPIs

We wanted to know whether Medicare's demand that an NPI be placed in secondary provider slot, even if it's the wrong one, was really the right thing to do. Our question to the official standards body was dead simple:

In Medicare's guidance to its billers, it states:

"If, after several unsuccessful attempts to obtain the NPI from the ordering, referring, attending, operating, other, service facility provider, or purchased service provider; CR 5890, from which this article is taken, requires that (effective May 23, 2008) the provider or supplier who is furnishing the services or items report their own name and NPI in the claim’s ordering/referring/attending/operating/other/service facility provider/purchased service provider fields."  (MLN Matters Number MM5890)

Using an ID/name other than that of the actual referring/ordering/etc. provider in the data element so designated seems a clear violation of the standard.  Please advise.

Also, if a secondary provider does not have an NPI (and is not required by law or contract to obtain one), what should the biller use instead?

X12's Response:

The 837 Implementation Guides contain usage and content requirements for the listed provider roles in conjunction with the services reported on a given claim; for example, Attending Physician. Name and Identification Code data elements are for the reporting of information pertaining to the person or entity performing the provider role designated by the Entity Identifier (NM101) qualifier in that loop.

The Trading Partner Agreements section of the Implementation Guide’s Purpose and Overview (Frontmatter section 1) states that trading partner requirements may not modify the requirements in the Implementation Guides. It further states that trading partner requirements may not modify the definition, meaning, or intent of the Implementation Guide.

Regarding the usage of NPI, when the Implementation Guide requires a provider ID, the use of NPI is required when mandated by the NPI rule. Other identifiers are available in the guide when NPI is not required by the rule.

What does X12 recommend? Read on...

Medicare to Plug NPI Hole with HIPAA Violation

I'm afraid to go back to Baltimore.  I've enjoyed a long and fairly collegial relationship with the folks inside CMS, both on the regulatory and the Medicare side of the department. Sure, I've challenged them on occasion, and we sometimes have agreed to disagree, but we tend to agree that we are, after all, pulling in the same direction in our own particular way.  They as the regulatory body that oversees an entire sector of the industry and the largest health plan known to humankind; I as a humble IT analyst and blogger from Tulsa, OK.

Everything was fine until Medicare NPI. We understood each other.

A Cyclops Has No Depth Perception
But recently I had to go out and poke them in the eye. I'm not sure if they noticed, but it seems they blinked, one way or the other.  And the blink is worse than the little National Provider Identifier mote I was trying  to dislodge in the first place.  See, it seems that they got around the not-everybody-has-an-NPI-so-how-can-you-insist-billers-provide-one problem by simply requiring that providers who want to get paid will reprogram their systems to violate the X12 standard and CMS's own regulations.

Is 5010 a Year?! Why HIT Standards Take So Long...

You thought I was just being clever last week when I quipped, "These umbrage-and-edit timelines rachet out to make the electronic claim standards developed three years ago available for widespread adoption sometime after the the turn of the decade, even with optimistic dependency scheduling."

Oh, no.  I had inside information.  And that information became public this week.  The North Carolina Healthcare Information and Communications Alliance and The Workgroup for Electronic Data Interchange have been working on a real live MS-Project-based timeline to show regulators and industry analysts just how much time is consumed in developing, adopting and implementing HIT standards.  The equation for the 5010 version of the electronic claim and other ASC X12 administrative transaction adds up to 2014 -- that's seven years from now to implement a standard I helped smarter people finalize almost three years ago. 

According to Holt Anderson, Executive Director of NCHICA,

“Our estimate is based on the key assumption that a proposed rule on 5010 will be published in June 2008, and if only minor revisions are made, a final rule will be published in 2010. It is projected that it will take three years to move to limited production of new standards and one year to move to full compliance, bringing us to 2014.”

Don't believe it?  Check out the details on the WEDI/NCHICA site devoted to the study.  And if you still don't believe it, download the MSP file and plug in your own assumptions. Heck, join in the conversation on their listserv!  The link says "membersonly" but it's supposed to be open to everybody.  If you have any difficulty subscribing, shoot me a note and I will inform the powers-that-be.

Medicaid Plans to go NPI?

On today's WEDI NPI call, several different sources talked about various state Medicaids' plans to move to NPI claims processing.  As we have cautioned, the CMS Contingency announcement allows for health plans to move to NPI processing at any time up to May 23, 2008.  Plans can and will transition during the intervening months.  Some already have.

States mentioned on the call -- currently unconfirmed -- include Arkansas (hard cutover Oct 15),  California (accepting Oct 1) , Michigan (October schedule may be shifted to February), Montana 10/1, New Jersey 10/3, Oregon Dec 31.

Those dates mean nothing until we know what the specifics are in each case.  Will they allow dual use submission of NPI plus legacy ID?  Is it only the billing/rendering provider loop, or do they expect to see NPIs for attending, referring and ordering providers also? Do they have specific plans for implementing pharmacy transactions?  If so, what will they do with the pharmacy claim when a patient's physician refuses to obtain an NPI?

More when we know more....

Link to All CMS NPI FAQs

Many moons ago, I wanted to share a query string that would bring up all CMS FAQs that include the term "NPI."  That was preferable to linking to specific items, because new items were being constantly being added.  I did the search query on the CMS site, which created a URL that was a mile long.  I systematically eliminated components of the string until I came up with something that produced the desired results, but was only a furlong or two in length.

I've given this out before, but I didn't have a direct, isolated link on my blog, so here it is.  You can click on the big ugly string, but that often gets broken in pieces when you copy/paste/send via email, so if that's an issue, you can link people to this blog post by copy/pasting the second string.  (I don't use tinyurl because I'm not sure what they are selling to do what they do for free.  I am selling mostly free information with a few fee-based webinars and mostly-free presentations and white papers thrown in).

Big Ugly String to CMS NPI FAQs
http://questions.cms.hhs.gov/cgi-bin/cmshhs.cfg/php/enduser/std_alp.php?&p_page=1&p_search_text=NPI&p_new_search=1&p_search_type=answers.search_nl&p_sort_by=&p_gridsort=4%3A2

Short Friendly String to this Blogpost
http://blog.hittransition.com/2007/08/link-to-all-cms.html

Contest: NPI Dissemination Roulette

An erstwhile reader suggested that, with yet another indefinite delay of the release of the NPPES data, I should "open a book" on the actual date that CMS will go online with the NPI Registry.  I'm sure she's not suggesting anything illegal, so I've devised this simple contest:

Email me (martinjensenAThittransition.com) your estimate of when you think the NPI Registry will go online and why you think the date you predict will be the real one.  I'll post the most interesting responses in a future blog, though I will keep all contributors' names a closely-guarded secret.  FOIA rules do not apply here!

In keeping with the spirit of the topic, the end of the contest is indeterminate.  I'll quit accepting submissions when the new target date is announced, which could be any minute now.  We know that date doesn't necessarily mean anything, but its publication as the new definition of Real Soon Now provides a handy stopping point. If the registry goes online without such an announcement, well I guess that would mark an endpoint to the contest, too.

We'll present the winner a major award: one of our beautiful "CMS is like a box of chocolates" coffee mugs.  (If you decide you must have one and cannot wait for Real Soon Now to arrive, you can order one from our HIT Bling! Cyber Cafe.)  The prize will go to the person who comes closest to the actual date the NPI Registry goes live.  If there is a tie, we'll draw one submission at random from the winning estimates.  "Never" is a legitimate estimate, but remember that your chances of getting the mug decrease with the number of winning entries. 

It may also be difficult to determine when to award the mug in that case, since CMS may never admit that they will never release the data.  Remember the National Plan ID standard?

Prize value is $15.95 plus shipping and handling, which should keep you within the boundaries of any organizational ethics policies.  If not, you can still play -- just indicate that you want the mug shipped to the charitable institution of your choice.  I'm sure your local hospital will appreciate the gesture.

CMS Pulls a Lucy - Dissemination Football Snatched Away

I don't know about you, but I was up at midnight to see whether the promises of the long-awaited data dissemination policy had been actualized.  I anxiously clicked on the NPI Registry link and got the following familiar non-information:

NPI Registry is currently unavailable.

Please try again later.

Dissemination Delayed is Dissemination Denied
No NPI lookup. This morning the message persisted.  So I called the technical support number and spoke to an NPI Specialist.

"CMS has decided to delay the deployment of the registry. It could be next week; it could be longer."

They had already decided to delay it until August 1.  Does this mean they have decided to delay it again?

"That is correct."

Do I feel like a blockhead?

That is correct.

This Time, She Really Might Let Me Kick It
Unlike NPPES, we at the HIT Transition weblog don't rely on single-source reporting.  My partner Michael called again.

"CMS has decided to delay deployment and will announce any information on their NPI Website."

Whump!
While I was composing this post, This confirming message appeared on the CMS NPI Data Dissemination page:

CMS is delaying the deployment of the NPI Registry and the dissemination of FOIA-disclosable health care provider data from the National Plan and Provider Enumeration System (NPPES).  Additional information will be forthcoming on this web page.

Fussbudgeting for Privacy
A source indicated that AMA sent another letter off to CMS last week.  I couldn't dig it up on the AMA website yet, but if anybody can share a copy, I'll let you know.

Whether that tipped the scales or not, you can bet that CMS is anticipating a lot of angry calls from providers who feel a public posting of their NPPES data (sans SSN, birth date, country of origin, etc.) constitutes an invastion of their privacy. 

Just Another 10-Digit Number?
Will they get any calls from other providers who are miffed that the delay means they still can't obtain the NPIs they need to get their own claims paid?  I guess that's part of the calculation.

In case you needed them, that NPPES contact information is:

1-800-465-3203 (NPI Toll-Free)
1-800-692-2326 (NPI TTY)
customerservice@npienumerator.com

CMS Moves Dissemination Goalposts, Tees Up for 8/7

Sometime last night, CMS posted a bunch of news to their NPI Data Dissemination page.

They must have reconsidered the issue of leaving the first data file out there for perpetuity (including all the privacy-concerned providers who somehow didn't get the previous messages about redacting addresses and numbers they don't want to share).  Now they say they will post a fresh file every month.  Deactivated provider records will simply disappear.  Neat, huh?  Guess we don't have to worry our pretty little heads about when a provider was deactivated or why.

The posting of the NPPES data file now has been given a definite date of August 7.  The link is http://nppesdata.cms.hhs.gov/cms_NPI_files.html

In answer to some of the questions you may have...

1. Yes, it will be one big'ol CSV file, accompanied by a Readme and a code value reference.  (See important note below)
2. Approximately 340MB zipped, 800MB expanded
3. "During testing, CMS was able to use Helios Textpad, Boxer Text Editor and Microsoft Access 2003 successfully to view the file."
4. No tech support.  Thanks for asking.

Type 2 Re-do
Contrary to the Data Dissemination Notice, no EINs will be in the data.  They say they found some SSNs in the mix.  They say they'll release EINs when they are sure there aren't any SSNs in the field.  In the meantime, this will make one of the most significant queries impossible to run: "How many subparts did this organization enumerate?"  It also means that the data structures, queries and exports you make now will need to be revised when the data element is added.

Gee Maybe There's a Pattern in that 9-digit Number....?
They also found a data solution to the "accidental disclosure" issue -- where a practitioner's SSN was embedded in an Other Identifier field: "CMS is suppressing from display in the NPI Registry and in the downloadable files any SSNs or IRS ITINs that remain in any of the FOIA-disclosable fields in the records of health care providers who are individuals."

"Suppressing from display?"  Why not just delete those numbers at the source?  Oh yeah.  Medicare gets its access to NPPES under a Data Use Agreement, not via the Freedom of Information Act.  Maybe they need those secret numbers for their crosswalks.

Missing Link Discovered!
Most importantly, the Readme, code values and a header file are posted now.  You can download them from the bottom of the page.  OOPS!  The link to the header file is bad.  I derived the right URL.  Until they get it fixed, you can download it here.

.

NPPES File: "Real Soon Now" Revised

So the NPI Registry is supposed to go online Aug 1, which is Wednesday.  But in a departure from previous announcements, CMS now says it may be "about a week later" before anyone will be able to download the entire file.

My suspicion? They're going to move the file's as-of date from July 15 to "the last possible minute," so there isn't a perpetual repository of "p___ed off provider" records out there.  Remember that the first release is supposed to become the baseline data, after which they will post monthly add/mod/suspend updates.  If un-redacted private data is out there on Day 1, it will be there "forever."

A more skeptical thought?  They're floating the repository site as a trial balloon.  Will providers love it because they can finally look up all the different NPIs they need to submit claims?  Or will they hate it, because they listed their condo as a business address?  (That would go to support their annual 1040 writeoff, though....)

But the NPPES data is finally going online!  Okay, Lucy...you hold the football, and I'll come running up and kick it.

(NOTE: See numerous updates on this issue by clicking on the NPI - National Provider ID category in the right hand margin.)

Medicaid Taxonomy Requirements are Booming

Back in 2004, the NMEH/WEDI Survey on Provider Taxonomy showed that many Medicaid plans and some commercial plans (based on response population) would be looking at Provider Taxonomy codes as part of their NPI remediation strategies.

Provider Taxonomy is a 10-character code that indicates practitioners' specialty and/or subspecialty designation, or organizational care setting.  It's a situational data element in the 837 electronic claim formats, and up until the time of the survey, had been sparsely employed in its "when necessary for adjudication" context.  Since that time, we've been working to alert the healthcare community about some of the pitfalls of using this poorly understood, but sometimes necessary, code as an NPI tie breaker.

So we crammed about four years of research into a 90 minute webinar, which we've given a couple times in the lead-up to the NPI compliance date.  May 23 has come and gone, and with the contingency announcement, so has a lot of the momentum in the NPI universe.  Still, we wondered whether there might still be interest in Taxonomy.  Had the survey's prediction that taxonomy would gain prominence in healthcare EDI come to pass?

We did a Google search for the answer.  Here's what Google said.

We've decided it's probably a good idea to do the webinar again, so we'll be scheduling for the end of August.  We'll include a status report on which payers have added Taxonomy to their requirements and what to do to keep it from bogging down your claims. [June 2008 Update: We are hosting another session in July this year.]

CMS Lists Common NPPES Mistakes

CMS-the-regulator has rescheduled release of NPI data for the end of July, but has warned providers to update their records by the 15th or risk dissemination of private and/or bad data.

Now CMS-the-payer is warning providers of specific problems in their NPPES record that might lead to Medicare crosswalk errors (read "unpaid claims").

Check it out at MLN Matters SE0725.  It's a pretty helpful document, and contains lots of good advice to those providers who don't bill Medicare, too.  Also contains useful stuff about how Medicare will map NPIs from 837 Claims to 835 Remittances.

Crosserwocky

An inside story from a provider impacted by the kind of Medicare crosswalk snafu I described yesterday.

NPI Jaywalking: UPIN Vacuum Leaves Crosswalks Unguarded

Any time the government discontinues a service -- particularly a free service -- there is bound to be grumbling.  Still, as taxpayers, we have to recognize that when the cost exceeds the value, it's important to retire those programs, and the sooner the better. After all, how many billions are wasted every year through the continued funding of once-useful or well-intentioned public services that are no longer needed?

When it comes to the issuance of UPINs to Medicare Providers and the free public lookup through the UPIN Directory, though, the recently announced May/September shutdown dates have many crying, "too soon!" Providers and some other parties (certain private payers, repricers) make the case for a continuing need for UPINs during the transition to NPI.

On Monday's WEDI NPI Subworkgroup call, we heard some pretty compelling testimony in support of that argument.

Paper Cuts

I keep telling people not to mess with paper.

So, while those of us who focus on electronic transactions are trying to work our way through the National Provider Identifier transition, there come a couple of "minor" news items regarding the "new" good old paper forms.

CMS-15oops!
First, the CMS-1500 professional claim form (still commontly referred to as the HCFA-1500, a decade after the Health Care Finance Agency became the Centers for Medicare and Medicaid Services) was found to have a major glitch.  The format approved by the National Uniform Claims Committee got some sort of minor tweek by accident, which left the federal to issue its own -- incorrect -- version of the same thing.  Looks like millions of copies were printed according to the bad specs, leaving CMS to issue a warning a couple weeks ago.

Delaware Medicaid NPI: Little State, Big Bang

For most of the US, the NPI Final Rule becomes mandatory on May 23, 2007, but in the state of Delaware, Medicaid billers have already hit the deadline -- two months ahead of schedule. According to the implementers of the system, this is not news.  Delaware Medical Assistance Program's providers have been told for months to expect the early deadline.  An admirable number of face-to-face meetings and multiple methods of outreach have taken place.

Light-Switch Cutover
The early transition is allowable under the Final Rule -- a fact that CMS has been clear to make numerous times in the past.  What disturbs some observers, including this one, is that Delaware's aproach includes no dual use period for transitioning from legacy IDs to NPI.  They planned to shut down their legacy system that relies entirely on proprietary identifiers one night, and bring up a new system that relies entirely on NPI the next day.  Good riddance, they say, to all those duplicate records.  NPI all the way!

Consumer Directed Health Care and Real Time Claims

Just got done with the first day of the X12/WEDI Real Time Adjudication Conference.  Some are now abbreviating this as RTCA (for Real Time Claims Adjudication),  What's RTCA, you say?  Well, that's one of the questions we're debating.

Basically, the concept means the patient walks in, gets treatment and the provider can submit the claim, get the health plan's payment amount (but not necessarily the payment) and the patient responsibility amount -- all before the patient leaves the office.  The provider gives the patient the bill and receives payment or at least an accurately quantified promise. 

The WEDI/X12 conference was just announced a few weeks ago, but there are a couple hundred movers and shakers here in Reston, Virginia.  Why the sudden interest?  In an acronym, CDHC: Consumer Directed Health Care.  Or, more to the point, CDHC as manifest in High Deductible Health Plans.  The Cure for Healthcare is making the patients responsible for their own care.  But giving the patients more responsibility can't reduce healthcare costs if they walk out the door and don't pay.  That's not patient responsibility -- that's industry irresponsibility.

The good news for us is, it's a perfect storm for introducing a new technology: RTCA.  RTCA could capture that elusive patient responsibility that is the core premise of CDHC.  There are lots of incentives for everyone to make this work -- and soon.

Oops Again - Medicare Crossover NPI Glitch Not Solved

Remember how Medicare bounced a bunch of crossover claims last October, but didn't get around to disclosing it until November?  The COB problem stemmed from zero-filling NPI fields, resulting in noncompliant secondary claims.  They promised that a fix was in the works, but the fix didn't take in some places, including Iowa, South Dakota, Kansas, Nebraska...okay, here's the whole list:

Taxonomy Transitions

January 2 marks the implementation date of the taxonomy code requirement for Medicare Part A claims.  So far, I haven't heard of any major challenges.  That may be due in part to the fact that M/C seems only to be applying the requirement to claims that are being submitted with NPIs.  Of course, each contractor has to decode the change requests and implement them, so your mileage may vary. [Note: Late in the contingency period, Medicare lifted its Taxonomy requirement, finding that the rules it had imposed on providers resulted in poor matching results. You may still need to submit taxonomy codes on Medicare claims for the benefit of secondary payers who receive crossover claims.]

HITTGroup to Host Taxonomy Webinars

You may have read some of our previous posts on Provider Taxonomy.  Our search engine hits show that it is one of the major topics that brings new readers to our site.  Why is this relatively obscure code set which indicates a type of healthcare facility or a practioner's specialty/subspecialty so interesting?  Three reasons:

1. It's the only segment in the 837 electronic claims standards that is exclusively mandated at the receiving payer's discretion.
2. Until now, a mere handful of payers have excercised that option (a few Medicaids and, reportedly, even fewer commercial plans).  However, because of the disappearance of payer-assigned proprietary provider identifiers under the new NPI rule, many more payers are considering including it in their NPI remediation strategy.
3. It can be extremely difficult for providers to implement.

Street Cred
My implementation experience with taxonomy goes back to mid 2002, when the provider I worked for learned that our state Medicaid program was converting to an 837-only claims system as of 1/1/2003, and that provider taxonomy was to be required on a number of provider loops, including Referring Provider.  Since then, I've negotiated with trading partners and debated the issue in X12.  I led the team that conducted a national survey of actual and anticipated uses of the segment in 2004, and have participated in ongoing discussions with both industry representatives and standards development organizations.

A Look at the CMS Data Use Agreement

Yesterday I published a story suggesting that executing a data use agreement (DUA) might be an alternative to waiting for CMS to publish and finalize its long-awaited NPI Data Dissemination Policy. I have since received confirmation that this is, in fact, the case.

But sources have also expressed concern that CMS does not relish the thought of being inundated with such requests, and that, as owner of the data, CMS would be in the position to accept or reject them as they see fit.  They may not be in a mood to approve hundreds or thousands of such requests while that formal disclosure policy, with its CYA benefits, is 'finally about to be released.' 

Perhaps a look at the actual form, CMS R-0235, with respect to the NPI, would be in order.

NPI Data Dissemination vs. Data Use Agreement

Just got a tip from a colleague that CMS may be allowing access to NPPES data (the NPI database run by enumerator Fox Systems) prior to the release and approval of the much-delayed Data Dissemination Notice. 

Big News Day
For people trying to solve the National Provider Identifier problem, this would be bigger news than the simultaneous announcement by CMS parent HHS that Robert Kolodner, chief health informatics officer at the Veterans Health Administration, will take on David Brailer's job, at least on an interim basis.  (It had been suggested that it would be hard to get someone from private industry to take on the review process, much less the role, for an official appointment, given the short period of time left in the administration's tenure  This fits with the indication that Kolodner would serve as acting national coordinator for health information technology.)

Back to Data Dissemination
The hue and cry for access to NPI data has been growing steadily since we and others first started asking about it after the release of the final rule.  "Real soon now," was the reply, as CMS wrestled with federal regulations regarding personal identifiers and external pressures to keep a tight lid on the as-yet-undeployed physician identifiers.

Without access to this data (and after many delays in the anticipated release of the policy), healthcare organizations have been relying on haphazard and error-prone point-to-point exchanges of NPI and related data.  Not just payers, but provider organizations.  Hospitals, reference labs, physicians who require referrals and preauths -- anyone who must list other providers on their claims -- were slowly beginning to realize how difficult it would be to send NPIs without the ability to look up NPIs. 

Worse, the early adopters were discovering a nasty uptick in demand for extra paperwork -- no standard procedure exists, so each payer was devising their own way of obtaining and verifying NPIs. Medicare led the way by requiring a hardcopy of the NPPES notification from the enumerated provider, which, flimsy as it was, remained the only method of NPI validation sourced from NPPES available to an external party.

Medicare Makes It Taxominally Clear

Another slew of information from Medicare last week about their NPI plans.

One particular question asked by providers on last week's WEDI NPI call was answered in the affirmative by official FAQ.

Q: We enumerated our organization just the way you wanted us to -- one NPI per Medicare (OSCAR) number.  Do we really have to send you provider taxonomy on our institutional claims?

A: YES! [NOTE: Late in the contingeny period, this answer changed to "nevermind." Medicare found its instructions to providers regarding taxonomy resulted in poor crosswalk results, and reverted to other tactics. You may still need to provide taxonomy on Medicare claims for the benefit of secondary payers, however.]

Provider Taxonomy: Crosswalk Enabler or Gridlock Generator?

With Medicare's first-mover announcement that they will require Provider Taxonomy on electronic claims, we can expect a flurry of payer revelations that they also need the provider specialty/type of facility code to manage their NPI-to-legacy crosswalks. [NOTE: Medicare has since been first-mover to abandon its complex taxonomy instructions in favor of other crosswalk strategies. Other payers, however, do rely on taxonomy, which is why you might want to continue submitting such codes on your Medicare claims.]

The real problem the industry now faces is how to reconcile various -- and conflicting -- payer-assigned taxonomy values.  Our experience in Oklahoma (OK Medicaid began requiring provider taxonomy in January 2003 as part of their 837-only HIPAA Transactions and Code Sets remediation) suggests that the assumptions that systems designers make may not be workable in the real world, especially once providers are instructed to begin submitting taxonomy code values to multiple payers.
In a nutshell, the misconception goes something like this:

To the payer-side designer, Provider Taxonomy is regarded as a secondary key by which to resolve NPI to a single legacy ID:

NPI(1)+Taxonomy(A) --> Legacy X
NPI(1)+Taxonomy(B) --> Legacy Y
NPI(1)+Taxonomy(C) --> Legacy Z

The provider submits the key that matches the payer's singular stored value on the legacy record, and it unlocks their legacy lookup.  In truth, Provider Taxonomy is squishier -- more of an attribute -- where several values may be equally accurate in describing the provider.

CMS Commits to NPI Realities

Readers might think I've been a little critical of CMS of late.  True, I didn't like their timing on adding the NPI to the Medicare 855 Enrollment forms.  Or the way they did it.  Or the way they pressed organizational providers to define subparts according to Medicare's view of the world.

More recently, I chided them on their new requirements for provider taxonomy on Institutional claims.  Not on adding taxonomy per se, but on their peculiar "payer mandate" that employs a baroque logic it expects IT-strapped providers to decrypt in order to send claims that will get paid.

Just Lost a Gig

I just learned that a promising prospective client decided not to have me jet in and solve all their NPI problems.   The project manager had been optimistic and enthusiastic, but her management opted to go with a local firm that had the backing of an excellent national HIT consultancy.  (Nice to lose out to the best, right?)

My loss could be your gain...I now have a four-week hole in my near term schedule.  Anybody looking for an NPI guy?  Drop me a line.

Medicare Clarifies NPI Requirements for Secondary Providers

Medicare just posted a new MLN Matters article about how NPIs will be processed for "secondary" providers, such as the Referring Provider, Ordering Physician, etc.  They seem to have taken the wise position that they can't insist on receiving data that the billing provider does not have access to -- or which may not exist at all.  With CMS's draft policy on NPI data dissemination pushed back until October, they seem to have come to terms with the fact that billers won't be able to look up an NPI for a physician they don't know.

We pointed out the logical inconsistencies -- and NPI implications -- of requiring such unobtainable information in a prior post, Which Doctor? Say Goodbye to OTH000, MD.  We also raised some concerns about the presumption that a physician would need to be enrolled in Medicare to refer a patient during conference calls with CMS on the surrogate UPIN issue. (This is one of the reasons submitting providers gave for using the surrogate UPIN OTH000.)

Medicare will Require Taxonomy for NPI Remediation

CMS has some bad news for all the provider organizations who decided the easy way to enumerate their NPIs was to break into subparts according to their existing Medicare numbers.  ("Five Medicare numbers?  We'll just get five NPIs.  What could be easier for CMS than a one-to-one match?")

That approach, it seemed, should keep the provider's giant Medicare claim volume safe while creating problems only for those pesky commercial plans that wished for one NPI per tax id number.

Medicare has some news for such accommodating provider organizations. You're also going to have to send the appropriate Provider Taxonomy code [see MM5243] -- at least on institutional claims.

Let me try to explain what that means in English.

HIPAA ROI Found Hiding In AHIP Survey

An interesting report entitled "An Updated Survey of Health Care Claims Receipt and Processing Times, May 2006" was just released by America's Health Insurance Plans (AHIP).  You can read about it and download the free report here.  As is oftentimes the case, it's not what the report says that's important, it's what the survey numbers themselves reveal.  Basically, electronic claims volumes are up -- a lot -- since the pre-HIPAA days of 2002.  But the sponsors don't trumpet the success of the industry's collaborative effort for Administrative Simplification, but instead suggest that “these data clearly show the best way to speed claims payment and to further reduce administrative costs is not through costly, new ‘prompt pay’ mandates, but rather to continue encouraging greater use of electronic claims submission.” (AHIP president and CEO Karen Ignagni)

Whuzzat?  Prompt pay laws are generally targeted toward outliers -- excessive waits resolving individual claims -- not on improving average turnaround times, which is where the data is focused.  More to the point, the survey reports huge -- really huge -- increases in electronic claims submission for the window of time framing implementation the HIPAA Transactions and Code Sets rule.  Based on aggregate data representing 25 million claims from 26 large and small US health plans, "the percentage of claims received electronically was 75 percent in 2006, up from 44 percent in 2002."  But wait, there's more....

CMS: Dr. OTH000 Can Remain On Staff

I'd this heard from an extremely credible source last week, but was waiting for an announcement from CMS: They've rescinded their instructions to deny Medicare professional claims containing Surrogate UPIN OTH000 in the Referring or Ordering physician loops.  It's late in coming -- Medicare contractors have been under instructions to implement on April 1, and one hopes they have time to undo the damage.  Providers that encounter problems are advised to forward links to Transmittal R752CP.

This is good news for providers today, but may suggest great news for all in the transition to NPI.

How Many Others? The Cost of OTH000

When Medicare first announced that they were excluding the use of Surrogate UPINs in certain situations, we were worried about the impact on provider billing.  There seemed to be a lot of exceptions to the "one doctor, one ID" ideal that lies behind any strict identifier requirement.  What about residents?  What about retirees?  What about non-Medicare doctors?

Clarifications from CMS provided some temporary reassurances -- we wouldn't face many of these hard questions until it was time to implement the surrogate-free NPI schema.  Providers can still use RES000, RET000, VAD000 for the time being.  The exclusion would apply only to OTH000 on Part B claims, and only in the Referring and Ordering provider contexts.

This narrowing of scope resulted in a significant reduction in the overall impact of the policy.  How much difference could it make if you were missing a couple of numbers?  Well, one provider discovered that, despite their best efforts, it might cost them over a quarter million dollars a year.

Read on....

Gorillas and Boas of Denial

My previous posts on Denial Engines have generated a goodly amount of interest and some degree of incredulity, which might be characterized as the "They wouldn't dare!" response, or perhaps, Denial Engine Denial Syndrome.  A system that payers could use to squeeze dollars out of providers' revenue stream based on ever-higher orders of edits?  There would be an uproar!  Providers would revolt.  Patients would protest!  Employers would take their business elsewhere!!!

Unfortunately, I not only doubt these concerns will be enough to hold off this new technology, I think the Denial Engine business proposition is so compelling that their widespread deployment may be a foregone conclusion.  Let me take it point by point.

Dr. OTH000 Revisited

A bit of an update on my prior post regarding the elimination of the surrogate UPIN OTH000 for Medicare billing.

First, it only applies to Medicare Part B (I suspect but have not confirmed that it is further restricted to Professional Claims).  Second, CMS affirms that it will apply only to Referring and Ordering physicians, not the other provider loops.  Third, at this point it only applies to OTH000, not the other surrogates that are available (such as INT000, PHS000, RES000, and RET000).  I expect VAD000 to be phased out, but it is not affected by the current rule.

Not as bad as I first thought, but it will still hit some providers pretty hard. 

The implications for NPI, however, remain significant.  Not so much because the current rule will impact NPI implementation, but because it serves as a wake-up call.  According to repeated assertions by CMS, no surrogate NPIs will be issued. 

Emdeon may shed PMS, keep Denial Engine

Emdeon issued a press release today that indicates it may shed its troubled practice management business, but assures investors it will retain its promising ViPS division.  Unlike the other tools we've dubbed "Denial Engines," ViPS focuses on fraud prevention rather than external edits. 

But fraud, like so many terms, is in the eye of the beholder.  After all, who can object to preventing fraud?

Providers: Beware the Engines of Denial

Earlier this month, I included the following item in my 2006 HIT List:

The Rise of the Denial Engine
There is a new category of software out there that is going to shift the balance of power, such as it is, between providers and payers. It’s a sophisticated claims analysis tool that lets payers add edits that are an order of magnitude more sophisticated than now exist. What’s more, they’re applied at the front end of the process. “What’s that? You conducted expensive process B without first taking simple blood test A? Sorry, according to the AMA, that’s against the rules.” While some provider billing systems already incorporate Correct Coding Initiative and Local Medical Review Policy edits, these new payer tools make their business case by demonstrating additional payer savings by going far deeper, across the whole range of claims. They sell for a pretty penny, and they justify that price tag by adding whole-percentage-point increases to denials and recoveries. How long will it take for these to penetrate the market? Less time than you might think.

I want to talk a little more about these Denial Engines because of three critical factors:

1. These new tools use rules-based logic and data repositories that go much further than payers' previous editing approaches.  The current generation of provider billing systems and claims scrubbing services weren't built to catch them.
2. They're extremely effective and can prove it with strong metrics, which makes them an easy sell.
3. Worst of all? They're ethical. Which is to say, they can provide the reasons for the denials, and often those reasons point to irrefutable third-party sources.

If there's good news here, it's that this creates a real opportunity for provider vendors (esp. application developers and provider-friendly clearinghouses) to differentiate themselves from their wrap-it/ship-it competitors.  A "free" clearinghouse might be less of a bargain if you discover that it leads you (directly or indirectly) into the mouth of a denial engine.

Which Doctor? Say Goodbye to OTH000, MD

Just in case providers were still wondering what the term “required” means, CMS has issued a policy that may test their ability to file claims under the NPI Rule – at least in a small way.  One of the aspects in which the National Provider Identifier differs from the Unique Physician Identification Number is that there is no allowance for unknowns:  Every Type 1 NPI refers to a single practitioner – no default values or temporary numbers.  No more fake docs.

In current practice, providers will submit a UPIN of “OTH000” when they don’t have a valid number for a doc that appears on one of their claims.  This can happen when they receive an out of state referral or when a “new” doc needs to appear on a claim, before they have received their UPIN from Medicare.  When OTH000 appears in a provider slot, the equivalent meaning might be phrased “We don’t know and/or you don’t care.”

Well, starting April 1, Medicare cares.  Even if you don’t have or can’t get a UPIN for the doctor, you have to send it or they’ll reject your claim.

ICD-10 vs. Regulatory Inertia

Congressional HIT advocate Nancy Johnson (R-CT) has drafted legislation that would require a conversion to The International Statistical Classification of Diseases and Related Health Problems Revision 10 (ICD-10) coding for diagnosis and procedure information in electronic healthcare transactions by October, 2006.  What's the problem?  The electronic transactions mandated by HIPAA won't support ICD-10.  What's more, even the most optimistic estimates see adoption of the new 5010 transactions (most of which are still in draft) no earlier than 2009, with a two year implementation window extending to 2011 or later.