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 were a bit surprised to hear so little about the impact of the new "NPPES must match IRS" policy we reported on two weeks ago and subsequently dug into in relation to the secret crosswalk logic the next day. Letters were supposed to go out right away. Providers should be getting them within a couple days, and then we would know the facts, which rarely get full exposition in formal CMS announcements.
We saw the search stats go up as people Googled IRS+NPI, IRS+NPI+crosswalk, etc., so we figured word must be getting out.
Wait For It...
Then comes this note posted to a public listserv: "We have had a pharmacy report that they received one - they said it took 9 days to reach them and they were concerned that they only had one day to react before being cut off!"
Totally Tubular, Dude!
Hello? If that's true, we have a big wave about to break. A potential tsunami that could make May 23 look like a...well, a pretty good breaker, with a tube and a long reach, but still, just a regular wave.
Continue reading "NPI IRS Letters Mailed with Short Fuse?" »
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...
Continue reading "We Will Help You With NPI Crosswalk Problems" »
Yesterday we posted the first public glimpse of the logic that Medicare is using to map incoming claims against providers NPPES (NPI) records to find matching Medicare PECOS (enrollment) records. If you missed it, you can download the spreadsheet here:
MatchingRecipesWithCounts05_27_08.xls
We also published an analysis of what CMS's new warning about NPPES/IRS mismatches might mean to providers who thought they were safe (see CMS Adds IRS Domino to Tumbling NPI Data). If you get a letter from CMS, will the changes they force you to make create a problem that requires an 855 enrollment (PECOS) update? If so, it could result in months of suspended claims.
The crosswalk file gives us a clue, especially since it gives daily counts of which rules are firing.
I did a quick analysis, where I segregated the organizational rules from the individual rules, and used the spreadsheets own matching statistics to measure the proportional impact. You can download it here: Download CrosswalkMatchAnalysis.xls
Pretty much anything that forces you to change an organizational EIN is going to affect the crosswalk, at least insofar as the rules represented in the spreadsheet (it's been pointed out, for example, that the crosswalk process may also look at Type of Bill and Revenue Code, which is not represented here).
Changes to the Legal Business Name, on the other hand, only affect 44.1% of the organizational matches, according to these volume figures. Providers would need to look at the specifics of the changes they make to see whether the modification is likely to cause a failure. The rules that affect LBN include various attempts to parse the data:
While it's hard to know precisely what these rules might mean in application, the first ("Match first 10 letters case Insensitive on consonants only") represents the lion's share of matches (43.7% of the total). If the changes needed to NPPES don't affect consonants in the first ten characters (before or after stripping out spaces, I wonder?), you may be okay.
Also, you may be safe if one of the other rules is able to produce a match, such as the rules that compare NPPES other ID fields, Other Names and/or zip codes.
If I were a provider whose claims are put at risk, I would want a lot more documentation than this file provides, but it does give us a starting point. CMS still needs to tell providers and their vendor partners more, and preferably in a public disclosure, rather than via a confidential release from a third party.
It's worth pointing out that if your claims are currently NOT getting crosswalked properly, changing the EIN and/or LBN per CMS's instructions might fix it.
(This is the post where we publish the Medicare NPI Crosswalk. SHHH! Don't tell....)
You might have noticed that we often slip in little advertisements, and occasionally even in-line mentions, of our products and services in these web posts. You know, for the Provider Taxonomy webinar, or the NPI Contingency Status Survey report, or, heck, even the HIT Grant Resources Directory for nonprofit fundraising.
Could it be, as we were once accused, that we are roiling up a false problem so that we can exploit it for financial gain?
How can I answer that charge in an appropriately professional manner?
No.
This Is Where We Prove Our Point
To prove just how bad we are at exploiting our arcane expertise for personal gain, I'm going to share something that just came over the transom. I haven't even had time to look at it very thoroughly myself, but it sure as heck looks like that long-anticipated Medicare NPI Crosswalk logic I've been railing about for months. You know, the thing that tells you how the field-by-field comparisons work, so you can figure out how to update your NPPES/NPI record and/or your PECOS enrollment data and/or your claims data to get paid.
Guess how much we're going to charge you for it?
That's right. Nothing. Download it here. MatchingRecipesWithCounts05_27_08.xls
And at this moment I have no idea whether this is the complete set of matching algorithms, or if they apply to Part A, Part B, or both. Looks pretty up to date, though, because one column includes stats of how many matches were logged against each rule on May 27. (And I should mention that, at first glance, it doesn't look nearly as brain-dead as I suspected, after all the provider horror stories. Wonder why they wouldn't want to publish it?)
We'll Help You Solve Your NPI Problems
We put together a simple deal to help providers who are having NPI crosswalking problems or getting claims rejected or misrouted for other reasons related to NPI. See We Will Help You With NPI Crosswalk Problems.
Back in the day, I used to believe that everyone in this industry was operating with the best of intentions.
Increasingly, though, I am starting to side with the most cynical of my provider colleagues who think that Medicare just doesn't want to pay claims.
Even as the Department's non-compliant, non-transparent NPI edits are quietly snarling claims all over the US, they have added a new flaming hoop to the race course: Your NPPES (NPI) data must not only match your OSCAR (Medicare enrollment) record, it must also match what the IRS has listed -- somewhere -- as your legal business name.(LBN) Here's what the notice says, and here are the staggering implications:
Continue reading "CMS Adds IRS Domino to Tumbling NPI Data" »
Thanks to Jose Luis Gonzalez at ANCO for posting a link to this document by Medicare carrier NHIC, which lists their top 3 NPI errors and how to solve them. Interestingly, the solutions generally seem to indicate a "less is more" approach -- take stuff out to get the claim through.
The one-pager is remarkably succinct and actionable. A good example of the kind of transparency we've been advocating CMS adopt house-wide. Though NHIC's tidy little message falls far short of a full explanation of how Medicare is crosswalking claims data to PECOS data, it should provide a good guide for providers encountering the edits they list (M402, M417 and M419; M381 and M379, respectively)
Medicare shoots out one carefully-worded story and it starts bouncing around the echosphere: Our Experts Agree, Everything Is Fine. This version comes from the HFMA website: "most of the Medicare contractors [are] reporting that over 90 percent of claims are NPI-compliant." We immediately posted our response, which said, basically, that "NPI-compliant" was a meaningless term, since it didn't address whether the claims would be properly crosswalked or paid, and that even 10% was an awful lot of rejections, when it comes to Medicare.
But in absence of any real news (like real adjudication rates, real payment levels, etc.) from Medicare, the story keeps bouncing around the HIT world.
Okay, here's some news, folks. Taken directly from CMS's own statistics, using a "per business day" calculation based on 251 working (and billing) days per year against unadjusted 2006 numbers.
Here's the other news: Medicare's numbers are grossly underestimating the problem. Why?
You want to talk about real numbers? We would need to look at before and after stats -- both dollars and counts -- for:
We don't expect any of these statistics to be publicized, of course. But we hope they are at least looking at them while they are telling the world that the problem is not really so bad.
"Keeping It" -- Real
And the most important little factoid is that the pain is not equally distributed. Many of the providers that are reporting problems can't get ANY claims processed. They are running out of time.
And so is Medicare.
[A note of thanks goes out to Cyndee Weston of AMBA, and the providers who have shared their stories with her, for all her assistance on this analysis and the rest of our recent NPI coverage. Many thanks also to Leslie Johnson and the front line folks fighting this battle over at the AskLeslie Network.]
Yesterday, an alert reader caught the notice that CMS had recinded MM5980, the Medlearn Matters article that told Medicare providers they need to violate HIPAA by plugging in their own NPI when a secondary provider (Referring, Ordering, Attending, etc.) did not have an NPI. (See Is Medicare Backing Off Noncompliant NPI Strategy?)
Now, an even more alert (or perhaps well-connected) reader, let's give her the code name Mrs. Plame-Wilson, says somebody inside CMS told her it's just a content-related error that prompted the memo to be withdrawn. The rules haven't changed since Medicare changed them. Don't worry, you can still add the spaghetti code to do that noncompliant kluge that will get your claim past our edits. (I'm paraphrasing here, to protect my source's Covert Ops status.)
In other words, "We're still going to violate HIPAA."
Which Gorilla Do You Listen To?
Behind this happy news come even more stories about small providers getting bad advice. One says that her Medicare contact told her to enumerate her small clinic, even though it is a sole proprietorship and the doctor/owner already had his own NPI.
Another said that Medicare of Florida/First Coast is telling her that she needs to put their service facility information -- for 200 sites! -- into the Billing/Pay-To loop instead of where the 837 rules say to put it (clue: loop 2310D is referred to in the 837P as "SERVICE FACILITY LOCATION"). And they also say she needs to submit the claims in 200 different batches.
XYZ
I'm also hearing about ZIP+4 failures -- which makes no freeking sense. I distinctly remember that CMS said they would subject provider addresses to USPS formatting specifications (DR instead of Drive, STE instead of Suite, etc.) as part of the NPPES enumeration process. Well, doesn't that mean ZIP+4?
Nope. And now Medicare providers are reporting bouncing claims because the crosswalk is expecting nine digits. (Tip: Go to www.usps.com and click on the ZIP code link in the header.) I wonder if those clever crosswalkers have figured out that not every address HAS a ZIP+4 (think "Iditarod").
It's fun! All the kids are doing it.
Cyndee Weston, of the American Medical Billing Association, has been gathering providers' tales of woe and adding them to our Provider NPI Nightmare Open Thread. You can add yours, too!
Are the Drugs Still Coming?
Pharmacies, according to my sources, are doing better, perhaps because NCPDP warned people well in advance about the absolute certainty that not all prescribers would have NPIs, and they came up with a standards-based (i.e. compliant and logical) way of dealing with the situation, instead of a proprietary, payer-specific kluge.
Alert Reader "ImNPIready" (I'm pretty sure that's a pseudonym) noticed that Medicare's instructions to falsify NPIs to get past their own edits seem to have been withdrawn. In a message distributed last night to Medicare Fee-For-Service lists comes the terse announcement:
Article MM5890 has been rescinded. While we do not normally remove articles from publication, MM5890 was removed per CMS instructions.
We've railed about this here -- like a lot of the issues we cover, it's got some technical nuance to it, but the basic instruction was "If you can't find an NPI for a secondary provider, put your own NPI in as the identifier for Referring, Ordering, Attending, etc." The problem with the instruction is that it overturns the fundamental principle of standards (that a data element refers to what it is supposed to refer to, not some other receiver-specific value) and the law itself (the Transactions and Code Sets Final Rule says no one can redefine or repurpose a data element).
What's Wrong With a Little Falsification Among Friends?
It would also set off a cascade of difficulties for everyone involved -- from the million or so Medicare providers who had to make sure that their bills to Medicare had this new logic (try to get your own ID to go in there when the name field is still supposed to be the real doctor) to the hundreds of secondary payers whose crossover claims were now going to fail their own (compliant) editing logic -- look for a secondary ID if no primary ID is given, or, in certain cases, allow the name with no ID whatsoever.
We'll see what Medicare replaces MM5890 with -- maybe something that is both pragmatic and consistent with X12's interpretation?
Medicare may love the numbers it is getting, but billing software vendor Misys wants to help their provider customers before they overwhelm their tech support department. So late last week, they sent out a fax broadcast. Download rejectionsfaxanon.jpg
Due to the high number of rejections, Misys is receiving a record number of phone calls to assist you with intrepreting and resolving these rejections. Here are some suggestions for how to troubleshoot rejection problems before calling Misys.
Given our own analysis, which suggests that, even after the Medicare SNAFU is largely behind us, providers will be confronted with a mounting series of unattainable, conflicting payer instructions, we particularly appreciated the validation in the vendor's first recommendation:
Continue reading "Misys Aids Customers with NPI Rejections" »
Despite widespread reports of significant claim disruptions, Medicare issued a note that says that "the favorable trend in NPI compliance is better than we expected with most of the Medicare contractors reporting that over 90 percent of claims are NPI-compliant, with some reporting 100 percent compliance."
I never trust it when anyone uses that c-word. CMS has assiduously avoided defining "HIPAA-compliant" in the long history of Transactions and Code Sets implementation, so "NPI-compliant" should not be taken to mean what this soft-pedaling would lead one to believe. (It's also worth noting that 10% of Medicare claims is an awful lot of unpaid bills.)
The real question is, "How many claims are getting through adjudication?" Even gettting Medicare to "accept" the claims is, as so many have learned, no guarantee, as notice of crosswalk failures sometimes appear in the form of ADR letters received weeks after the claim was "accepted." And yes, those claims could easily have been "NPI-compliant" -- in fact, lack of a legacy ID is one of the things that leaves Medicare's crosswalking process clueless as to how to pay.
If All Else Fails, Contact Someone Who Cares
In a pale acknowledgment of the problems that have already vexed some providers for months, the letter offers a glimmer of hope:
Some Medicare providers, physicians, other practitioners, and suppliers might experience cash flow issues during their efforts to implement the NPI. [CMS] will consider, in limited circumstances, the availability of advance or accelerated payments where facts and circumstances fall within the scope of the CMS regulations and/or manual requirements for such payments.
Gee, that sounds awfully qualified offer, but it's better than we've heard so far. Okay, where's that email address? Give me a phone number, an office, a form!
Medicare providers who may be experiencing cash flow problems related to NPI claims processing issues should contact their Medicare contractor to determine if they are eligible for an advance or accelerated payment. The Medicare contractor will review the request and provide a decision.
Contact the whole contractor? Do you have any idea how big those companies are?
More and more providers are reporting that they are contacting their elected representatives. Now that's what I call Administrative Simplification!
Full text of the CMS notice follows, for what it's worth.
Continue reading "Medicare Admits Few NPI Problems, But Allows Accelerated Payments" »
Breaking news from Joe Conn at Modern Healthcare: Medicare and Medicaid rejections are still huge after a week of effort, according to Miriam Paramore at Emdeon.
I have to tell you how brave it is of them to state this publicly, since their customers are likely blaming them for the problem. Isn't it the clearinghouses's job to fix stuff like this?
Regular readers will know that the smoking gun lies elsewhere. Just click on the NPI category on the right side of the page for about three years of clues.
I would also like to point out that the 25% rejection rate is not an indication that every provider will see their Medicare check drop to 75 cents on the dollar. Instead, many will see no impact at all, while a few (that's a word I borrowed from CMS to describe NPI crosswalking problems) will get a big fat goose egg.
It's almost seven and it's Friday night. Busy week. Gotta go, folks. Keep posting your own NPI stories on our Open Thread.
We posted earlier on the National Uniform Billing Committee's request for a 6-month extension to the NPI Contingency period. Their brothers and sisters in arms, the National Uniform Claims Committee, sent a similar letter, and a few days before the deadline, they seem to have gotten a response. This letter was distributed on a public listserve, so I don't believe it is confidential in any way: HHSresponsetoNUCCletter051908.pdf
We do not feel it appropriate to continue the use of contingency plans past May 23rd, as it is imperative that the industry continue its move towards compliance. There are likely to be some outlier technical and operational challenges, but we expect the industry will continue to resolve those together.
It's signed by Anthony Trenkle, Director of CMS's Office for E-Health Standards and Services. OESS is responsible for enforcing the HIPAA transactions regulations, including the NPI Final Rule. I ran into Tony at a conference last fall and he told me he reads the blog and said, "You know, you can call me if you have a concern." In fact, he encouraged me to call him when I got back to Tulsa.
I sent him a note saying that he was a busy man, and I was just a blogger, and it would probably be easier for him to reach me that for me to catch him between meetings. Guess he's been busy.
This is Going to Hurt You a Lot More Than it Hurts Me
I'll admit I had another reason for my reluctance to call. I've learned that CMS folks have a hard time saying anything that strays from a firm Company Line. Also that, even if they say something off-message in private, if I then publicize it, they tend to get taken to the woodshed, after which comes a public retraction or contradiction. Of course, as Chief of the HIPAA Police, Tony is more likely to be the guy waiting in the woodshed than the guy that gets hauled out there.
Still, my offer stands and my line is open. Tony? I think you have my number, if not, drop me a line. Otherwise, you can continue to read my advice here, or, if you want the full scoop, buy a copy of the NPI Contingency Status survey analysis, which explains how to get out of this mess we're in. (Readers, I should also point out that, via our "Buy-one, Send-one" offer, if you purchase a copy for yourself, we will send one to the government official or trading partner of your choice. Quite a deal. Why not send Tony a 100-page report to read over the weekend? Or maybe your friendly neighborhood Medicaid plan or Medicare FI?)
Back to the Letter from the Law
I'm thinking, "resolving things together" might ought to include asking your pals at Medicare to have sufficient staff available to answer the phone calls about those outlier technical and operational challenges, and getting the data entry of those handfuls of re-enrollments to happen in hours or days instead of weeks or months. But who am I to judge?
Oh, that's right. I'm a taxpayer. That makes me The Boss, right?
Handle it!
Earlier this week, we invited providers to tell their stories, good or bad. Most of the stories I've been getting have been coming in via email and phone calls. So many, I can't keep up. It's clear that we have a serious disruption going on. CMS's note to Medicaids (NPIDailyReportGuidance.pdf) said these elements would constitute a "Status Red":
So, providers, my blog stats are shooting through the roof as this implementation hits the fan. That constitutes "Media Interest." I'm pretty sure our coverage of the situation would not be considered positive, so we've got "Negative coverage" in the bag, at least at the national level. How about commenting on some of those other bullet points?
Unlike the daring civil servant I felt it necessary to protect, you might want to name the state plan, Medicare carrier or other private or government payer you are having trouble with. Facts are great, but opinions matter, too. How do you feel about the way things are going?
I'll turn off comment moderation for the time being, so your comments will display immediately.
Just click on the Comments link below to read or post.
In today's Modern Healthcare Online, Joseph Conn puts some numbers up on the board from a verifiable source. Emdeon's Miriam Paramore goes on the record, saying that their Medicare claim rejections have jumped by a factor of four since last week, from a typical daily rate of 6% to 24% this week. (See Claims processors see rejections spike with NPI)
It's worth noting that even this big multiplier may understate the issue. The typical daily rejection rate will tend to include a lot of coding errors. In general, the submitter looks at them, fixes the problem, and resubmits.
Then the provider gets paid.
This extra 18% may include a lot of claims that aren't so easy to remedy under Medicare's new rules. Crosswalk errors that require the provider to submit an update to the 855 enrollment form, for instance, may take weeks or even months to be reflected in Medicare's registration database. Until then, the claim payments might just go on permanent vacation, as so many providers have reported.
Likewise, the 6-fold increase in Medicaid rejects (from an average of 4% previously to 26% on May 23) will not only include a number of hard cases, but may also include the regional impact, since each state will have different edits and different internal system challenges. The 26% average will include a lot of states that are doing better, but some that are doing far worse at getting claims through.
And I probably ought not mention that clearinghouse throughput is not quite the same as adjudication and payment. Should I?
Nor should I mention that a lot of providers bill Medicare directly, without going through a clearinghouse.
That would be depressing.
Just when you thought Medicare was being a bit too hard-nosed about enforcing its idiosyncratic interpretation of the NPI Final Rule on an unprepared industry, along comes the news that they are willing to be flexible -- at least when it comes to filing their own claims. Check out this missive that just went to the secondary payers that receive Medicare electronic crossover claims:
Continue reading "Medicare Grants 30-Day NPI Extension -- To Itself" »
...in just a second. First, I need to ask, Why the heck is Medicare's NPI crosswalk -- the logic it uses to match new, NPI-only incoming claims to its archaic system of provider records -- a secret?
Why is it now, almost a week after NPI-day, as claims are bouncing up and down the street, that you are here -- instead of at the CMS site -- looking for the answer?
I'm not sure, but when I heard CMS's NPI Project Lead Marlene Biggs finally spit out a sequence of data element names on an April roundtable call, I couldn't write them down fast enough. So I sent a note to a contact inside the department to see if he could share it, even if it was just off the record. It was only a month before the deadline, I said, and the transcript would probably take weeks to publish...
I received a polite, "Thank you for your note, but I cannot share this type of information until it is offically released."
So they finally did publish the transcript, and here is what Ms. Biggs had to say, starting with some important indications that you may be experiencing a crosswalk problem:
Continue reading "Medicare NPI Crosswalk Secrets Revealed..." »
We've wondered why there is so little coverage of the NPI transition in the mainstream industry media. Sure, it's a little hard to wrap your brain around if you don't deal with this stuff day to day, but is it really that hard to tell the difference between Primary Identifiers vs. Secondary Identifiers vs. Primary Providers vs. Secondary Providers? Especially when you have Provider Taxonomy to break the tie?
Oh, yeah, now that I put it that way, I guess it is...
But one guy who consistently covers the HIT waterfront pretty well is Joe Conn, who writes for Modern Healthcare and American Medical News [Oops. Joe writes for Modern Healthcare, Modern Physician and Health IT Strategist, but not AMN. Our bad. - Ed.]. On NPI day, Joe logged one of the most accurate and comprehensive pieces on NPI we've seen so far.
And I'm not saying that just because he quoted me extensively. He actually got the story right.
Waiting for a bombshell? How about this one? I just got a note from a Medicaid worker at a state that asked to remain nameless with an attachment that tallies how their daily claims throughput has dropped from a healthy six-figure number to a fairly puny five-figure number. Comparing the average throughput from the last three pre-NPI days to the first three subsequent post-NPI days, the drop is over 70%. But the daily numbers decline even further from 5/23 to 5/27. Comparing the numbers from last week to yesterday puts them frighteningly close to a 90% drop.
If that sounds bad, then you definitely don't want to know about the crossovers they're getting from Medicare.
Those went from a robust five-figure number to a positively anemic three-figure number. A 99% drop. Guess they weren't ready for those NPI-only submissions from COBC.
Continue reading "Medicaid NPI Confession: Our Throughput is Down 90%" »
I'll use this post to aggregate some of the stories about whether the NPI is causing problems or not. Of course, some of the problems the current strategy is creating may not come to full fruition for weeks or months, but I'll update this post for the rest of the week with any stories that find their way to me. If you know of one we missed, drop me a line at martinjensen-AT-hittransition.com.
This one from the Long Island Business News gets some of the background facts wrong, but puts a very real face on the providers who are having the problems.
iHealthbeat summarizes a story from Government Health IT saying Medicare's Stewart Streimer thinks there may be some problems. They apparently missed the part where Streimer attempted to downplay the problems, but at least they got the part where he blamed contractors and, of course, the unready providers rather than laying any blame on Medicare itself, which ran the crosswalk project that all contractors were mandated to employ.
Some health care organizations have obtained multiple numbers for several locations and subsidiary organizations, despite CMS' intention for each doctor, hospital, clinic and other health care provider to have only one ID number.
Oh, really? I thought CMS's intention was for every provider organization to decide how to enumerate themselves. Oh, yeah. That was the intention of the legislation. CMS's intention was for everyone to use Medicare's numbering schema. Which, if I recall, relies on multiple numbers for several locations and subsidiary organizations.
The Government Health IT article says, "Streimer said he is cautiously optimistic because a test on May 7 went well, with nearly 80 percent of claims conforming to the new NPI rule."
I wonder if I could muster the same bravado if I were to inform 20% of my creditors that I was cautiously optimistic I could pay my other bills this month. But not necessarily theirs.
Wed 5/28 Update: Speaking of Paying Bills...
A Medicaid plan reports that their claim throughput is down almost 90% since last week. Which one? I can't tell you. Why not? Read it here.
Thu 4/29 Update: Read It Here
When I started this post, I thought it would be a convenient place to list the press coverage of the NPI story. Since then, I've learned that I'm writing most of the press coverage of the NPI story. People are sending stuff to me. It takes longer than a paragraph or two to get it all down. So I've been doing multiple posts a day all week. Instead of coming to this post, then, I just recommend you click here to see all the NPI stories we have posted under the NPI category. We'll continue to collect your first-hand accounts below, so check back for comments.
NOTE: If you have your own story, please post it to the Comments below. Be aware that whatever name and website link you use will be posted, too. It's okay to use a fictitious name if you feel it necessary to protect your identity.
In case you were wondering whether any of these National Provider Identifier end-of-contingency plans were going to go off without a hitch, I have great news! They promised to bring down the UPIN directory, where Medicare billers and others went for free lookups to the dodgy database of Medicare provider numbers on May 23, 2008 (after a previously scheduled disappearance brought howls of protest from an industry completely unprepared to rely on NPI alone).
And they did! I checked it yesterday and it was up. I checked it just now and it's a complete 404 -- no sign of life, no thanks for your business, no "Sayonara, suckers!"
This is just too much. I had no sooner got done posting my "I'm not gonna predict what Medicare will do next" message, when this came flying into my inbox from a friend. It's a forward of an automated message she received after submitting claims to her Part B Carrier last night.
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Claims Rejected in Error
The electronic data interchange (EDI) National Provider Identifier (NPI) prepass edits, requiring that the NPI only be submitted on each claim at every provider level, were inadvertently turned on one day early. Because of this, a large percentage of claims were rejected in error. In order to correct this, National Government Services is taking steps to resubmit the EMC file dated 5/22/2008. You may see duplicate claim notifications and/or rejections. Please disregard any NPI only rejections received between 5/23/08 through 5/27/08. National Government Services will have the matter resolved after the 5/27/08 system cycle.
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Welcome to Church Chat
Okay, so they did it one day early, and now they are putting off NPI-processing until after the three-day holiday weekend? How convenient!
So, let's see. Just what does this mean? So, just who do we think could be responsible for all this he-said/she-said and all these late-night computer buggies and all these promises made and promises changed at the very last minute?
My, my, my, my, my. Just who could that be? Could it be....?
We finally got our long-awaited NPI Survey Analysis report finished today. Is it too late? I don't think so. Many of the problems predicted by the report will take months to manifest -- unless the recommendations in the report are put in place to stop them.
Oh, actually, the report says the problems are happening already. But the policies will make them happen to more providers and more payers and more clearinghouses, more acutely. The canaries did not show us the way out of the NPI coal mine.
We didn't want to write a 100-page report. The data made us do it. The title may give you a hint about what we found: NPI Problems in Process: Would Extending the Contingency Only Make Matters Worse?
What Else? Oh yeah...
Today is also the day when Medicare says it will enforce NPI-only claims for its Fee-For-Service system. Most people -- even me, in a more unguarded moment -- thought they would throttle back, allow some flexibility. They didn't.
Technically, they still might, since the noncompliant logic they wanted billers to use has changed in the last week. First they said that if a Referrer or any of the other so-called "Secondary Providers" on the claim didn't have an NPI, billers should put their own NPI and their own name in those fields instead. Last week, they said, no, just the NPI. Leave the real name intact. Except for Service Facility. Then leave NPI blank. Got that?
This is a violation of both the standard and the law, both of which say that an organization cannot redefine a data element for their own convenience. That's not the point, at least not today.
Nevermind What I Said, Do Like I Say!
The point is, with less than a week to go, Medicare was issuing last-minute directives to fix problems they had created for themselves, and by extension (because they refused to back down) for the million-plus providers who rely on Medicare payments. Now that somebody has called them on it, proven they are violating the standard (if not the law) and even gotten them to admit it, are they going to bounce all those claims? Or are they going to slack off at the last minute?
I don't know. I keep saying I've quit predicting what CMS will do, because even when it seems obvious, I've usually been wrong. And then I go and predict again. Not this time. You'll have to find out when everyone else finds out.
Do You Think It Was Remittance-Free, Too?
Medicare says they were happy with the way their "Legacy-Free" day testing turned out, but I heard that the Secondary Provider edits were not necessarily part of that test, so it might not be a great predictor of what happens next. Also, I worry about the "handful" of providers whose claims got mucked up.
Gorillas have very big hands.
Four of them.
We'll be here on Tuesday to see what happens.
Hope you have all the drugs you need to get through the weekend. Just got a call from a PBM wondering how to match all his DEA numbers to NPIs.
On yesterday's CMS NPI Roundtable, the fine folks (and I truly mean that) from the Office of E-Health Standards and Services repeated their admonishment that they can't investigate a suspected violation without someone filing a complaint. You can remain anonymous, they said, but remember that if you do, it can be hard to reach resolution, because the process is designed to elicit a back-and-forth exchange between the parties to reach consensus.
They said, in the 500 or so transaction complaints filed thus far, there have been no instances of retribution.
(Go tell that to your CFO, quick!)
What they did not mention is that OESS never publishes the results of such disputes, much less details of the proceedings. What they did not mention is that there have been absolutely no fines imposed for transgressing the Transactions and Code Sets Final Rule in the four and a half years since the end of the October 2003 contingency.
(Thought Experiment: Apply those same enforcement rules to traffic violations and imagine what the fenders on your car would look like. That's what TCS looks like.)
But even as we careen toward May 23, with 80 - 90% of claims currently being submitted in a way that would fail the NPI-only edits Medicare insists it will put in place on that date (this according to our survey, based on provider's own reports of all claims, not just Medicare claims), who is going to volunteer to take on the biggest gorilla in the healthcare jungle?
Um, how about me?
Look, the reason I can say the things I say here, the things you readers tell me you wish you could say, but can't, is because my little company does not rely on Medicare for a single penny of its meager operation.
That's the good news.
The other news?
We rely on you.
You've already seen that we can and will file and prosecute challenges in the standards arena, when we submitted a direct challenge to Medicare's Secondary Provider edits (that eleventh hour change they talked about on yesterday's call went out via email overnight -- and it's still noncompliant, and it will still cause massive disruptions to provider revenues). It took a while, and we kept quiet about it, but we got the opinion we knew was right. X12 took the daring step to stand up for the rules we created together as an industry.
Will OESS do the same?
I'd like to see. Would you?
Here's the deal I will offer you.
You help us do it, and we will share the results here. Right in the great wide open.
We need to sell some papers. We need you to buy a copy of our NPI Contingency Status Survey report -- not cheap at $995 [Ed. note: there's a MAY DAY! special going on over at http://surveys.hittransition.com. The report is half price May 23 through 31.], but well worth the price of admission. You get the full results of the survey, plus the analysis of why continuing forward on the course we are on will snare the industry in a needless and heedless mess, and what can be done about it -- inside your organization and as an industry -- if we act now. And, under our Buy-One, Send-One deal we will send even an additional electronic copy of the analysis to the trading partner or government official of your choice. (This is a limited time offer. Your mileage may vary. Not to be taken with alcohol.)
The report will be available as soon as I can get all the rest of the words and charts poured into the massive document [Ed. note: Done. 106 glorious pages with hyperlinked citations of all the rules CMS is violating and misinterpreting and all the ways this is bolloxing up any plan for an NPI-based future. Dozens of charts, three spreadsheets with questions and answers, all de-identified to protect the innocent, and, of course, guidance to help you work through the tangle of contradictory demands being placed on your operational staff.] . But you can buy it now.
If we can sell ten copies -- just ten! -- we will take the fight to OESS to enforce against Medicare. We will tell them that admitting they are violating their own regulation is not enough. They need to stop it before the bounce claims from here to Timbuktu.
And we will share the process with you.
Go. Buy it. Help us out here, folks. We're doing this for you.
We eagerly dialed in to today's CMS NPI Roundtable call wondering how -- or whether -- they would deal with the opinion we sought out -- that Medicare's policy that providers falsify claims data by saying they had referred patients to themselves when a referrer's NPI was unavailable is, in fact, a violation of the 837 standard.
In X12's authoritative interpretation of their own guide, trading partners may not "modify the definition, meaning, or intent of the Implementation Guide." In other words, the Referring Provider stuff needs to refer to the actual referring provider -- payers (yes, even Medicare!) are not allowed to redefine what goes in there.
Because the implementation guides are incorporated into the HIPAA Transactions and Code Sets Final Rule by reference, this makes Medicare's demand a HIPAA violation. But it's again worth noting that this sort of shell game (once the province of wayward Medicaid plans who wanted providers to send nonstandard Type of Service codes in fields intended for other purposes) was so vehemently out of bounds, the language was added to the regulation itself, where it says that a Covered Entity cannot "change the definition, data condition, or use of a data element or segment in a standard." (§ 162.915(a), Federal Register / Vol. 65, No. 160, p. 50368).
In a remarkable bit of bureaucratic candor, Pat Peyton acknowledged, "We are aware that our policy is not in compliance with the implementation guides." (A previous caution to questioners had indicated that they would NOT be considering policy violations on this call, and anyone who brought up the subject would be disconnected.)
Interestingly, Medicare explained that they were doing this -- requiring that Providers develop a special, Medicare-only coding rule that would plop their own NPI into claims that would foul crossovers and, in fact, put the submitter (and clearinghouse, if any) in a state of violation -- for providers own good. I believe they used the phrase "to smooth the transition" to NPI-only transactions.
They also said, again, that sending only NPIs in such secondary provider fields is required by the NPI Final Rule. (It isn't, by the way. I looked. CMS has not been forthcoming with this cite, though they seem to repeat it on every call and in numerous FAQs and other guidance.)
Pat promised that there would be clarifications forthcoming as the industry moved toward NPI-only, etc.
Clarifications?
Let's make this clear: Kluging these claims is not easier than submitting them per X12 guidance, which says if no NPI exists, you should submit claims the old fashioned way -- with an alternative secondary ID. No change necessary.
Let's make something else clear: There is no reason to believe we will EVER operate in an NPI-only industry, save a congressional mandate for full enumeration. Perhaps using Medicare's enrollment requirements as a model, other health plans will start requiring NPIs on their claims (as indeed some have already done), but that will only reach the providers who file such claims. Not all do. Non-billing providers will still write prescriptions, will still refer patients, will still CARE for patients at both free and cash-only clinics around the country.
Penalizing providers who are trying to comply with the NPI Rule is not going to change this.
But in its attempt to force this to happen, Medicare is going forward with this explicit instruction: "Violate our laws if you want to get paid."
They did offer this one eleventh-hour zig: Maybe they only want the biller's NPI in that secondary provider Identifier field (not just Referring, but also the others -- Attending, Ordering, etc.) -- you can leave the real provider's name in the corresponding Name field. Oh, and if it's a Service Facility, you can leave NPI blank. But just that one. I'm sure they'll put that in writing in plenty of time for you to change that back to the way it was before you followed their previous instructions to replace both name and number on all fields.
And if you don't like it, just complain. Lines are open. https://htct.hhs.gov/aset
The full report includes dozens of charts, graphs and tables -- enough ammo to rock the most uncooperative trading partner -- and all the regulatory citations to back you up.
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The full report includes dozens of charts, graphs and tables -- enough ammo to rock the most uncooperative trading partner -- and all the regulatory citations to back you up. |
The survey provides a detailed look at facts-on-the-ground from various points of view. Institutional providers report almost 98% of their claims are going out with their own NPIs, but a full 82% of those also include their legacy ID to assist payers with proper matching and payment – a precaution that Medicare and other health plans vow they will not allow after the deadline. Another key concern is how billers will represent those practitioners – who may refer patients, order lab tests and write prescriptions – but who may have chosen not to obtain an NPI. This may be their right under certain regulatory exceptions, but will disrupt operations for the compliant providers who accept patients referred by them. Nearly a quarter of billing providers said they had been unable to obtain NPIs for 5% or more of such practitioners.
Other systemic problems include NPIs being stripped from the transaction by an intermediary before reaching its destination, reported by nearly half of providers responding, and difficulty meeting payer taxonomy (specialty code or facility type) requirements, listed by a similar number. Most disturbing, perhaps, is the almost 70% of providers who report receiving conflicting instructions from different health plans, such that “Fixing Payer A’s issue creates problems with Payer B.”
The survey results suggest that providers, who have been told for years now that the best NPI strategy is to update their records for accuracy and test early and often, seem to be discovering that inconsistencies beyond their control may ultimately make their NPI problems intractable. Even before the deadline, nearly 70% of providers report that payers are already rejecting, pending or losing claims based on NPI issues. 71.9% predict substantial payment disruptions if the nation goes to NPI-only on May 23, and 25% predict “substantial, immediate or short term service disruptions to patients.”
A most startling contrast came in the pharmacy segment, where a small cohort of providers reported great success sending their own NPIs, but dire problems collecting and submitting the new number for prescribers, who may offer only a scribbled signature for identification. Pharmacy Benefit Managers (PBMs), massive health plans that specialize in prescription coverage, showed a frightening big picture. Responses representing 101 million claims per month indicate that while almost 91% of claims were arriving with the pharmacies’ own NPIs, only 5.8% carried prescriber NPIs. Regulators recently posted an exceptionhandling allowance, but industry observers fear the guidance may be too little too late. One pharmacy respondent warns that “point of service rejects due to the nonacceptance of the legacy ID will result in customer service delays [and] risks of continuation of therapy.”
Comments collected in the survey suggest that providers, while most at risk, are not alone in their frustrations. One Medicare plan respondent stated that “There isn't enough time… to ensure there will be no disruption in payments.”
Providers report that this is already happening. One practitioner reported an inability to collect on Medicare claims since October, 2007. Another, a small hospital, said that the federal Centers for Medicare and Medicaid Services (CMS), which administers Medicare payments, had mixed up their NPI numbers, resulting in misrouted payments between three divisions which cost “many months trying to get it corrected. It caused cash flow to come to a halt for 2 weeks.”
A PBM respondent is alarmed that the NPI compliance date, May 23, 2008, falls on “a Friday before a holiday weekend, so after 5PM physician offices will not be available for stores to call for the NPI.” More than 8 million prescriptions are filled every day in the U.S.
As of May 9, Medicare continues to maintain its intention to deploy its NPI-only edits on May 23. Transactions submitted with a legacy ID for any provider identified on the claim, even referrers without an NPI, will be rejected.
The full report, “NPI Problems in Process,” and a free package containing the survey data and a public summary, is available at http://surveys.hittransition.com/npi .
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...
Continue reading "Medicare's Wrong... No Willy Nilly NPIs" »
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.
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.
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.
