NPI: Are we there yet? By Mark Martin
The following article, written by Mark Martin – Sr. Director of EDI Product Management at Sage Software – discusses Sage Software’s experience to date with National Provider Identifier (NPI) and delves into the facts and complexity of NPI, offering tips and insight.
March 1st was a key milestone for National Provider Identifier (NPI) in our industry. Medicare rolled out full NPI edits for professional claims. While over 90% of Medicare claims from Sage Software clients are passing all clearinghouse and payer edits, some claims are still getting held up by NPI-based rejections. For those of you who have cleared this hurdle without much problem, great job and congratulations! For those that haven’t successfully crossed this milestone, here are some lessons learned that you may find helpful.
Cold Hard Facts
Albert Einstein said; “If the facts don't fit the theory, change the facts.” I love that quote because NPI is ripe with theory, and success is deeply dependent on facts. Let’s start with theory. In theory, NPI will make transactions between you and your payers easier. In theory, NPI reduces the complexity that has existed since electronic transactions first emerged in healthcare. Electronic transactions, from one computer to another, rely on facts. Computers have no ability to interpret intent as humans do. Computers are black and white, yes and no, I found an exact match, or I did not find an exact match. In other words – it’s all about cold hard facts. Claims get paid on certain facts that your practice and your payer agree are accurate. For years that may have been as simple as your Tax ID number. You sent in a Tax ID number and as long as it matched what your payer had, the payer knew who you were and went about adjudicating your claim. In theory, NPI can be that simplistic.
But what are the facts?
When you purchase an item with a credit card, facts about you are read from the magnetic strip on the back of your card. Those facts have to match up with the credit card company’s computer in order to authorize your purchase. Do you know what is on that card? I know I don’t. I don’t have to know because the credit card company put those details on the card. They did not ask me to make them up, then try and sync up with their details. Unfortunately, CMS did just that. They asked all practices and providers to log into the National Plan and Provider Enumeration System (NPPES) and load in some facts. Then they generated a number for you - one individual NPI per person and a minimum of one main business NPI per tax ID - pretty straight forward. Now, in order to get a claim paid, particularly for Medicare, you have to send in a claim that has facts that match the NPPES database. Then, and here is the tricky part, those details now have to line up with facts in a separate Medicare computer. The logic is something like this; Mark=”A”, “A” is in NPPES database on Mark’s record, Mark’s NPPES record says that Mark used to be known as “B”, the Medicare computer knows Mark as “B”. Everything matches, so the claim passes NPI edits, and on to adjudication.
Sounds easy, why the complexity?
Sage Software’s experience so far is that the provider level NPI is pretty straight forward with few rejections occurring at that level. Most rejections today are associated with what is called the Billing Provider. It is the Business, or Organizational, or Type II NPI number. On a paper claim, it is roughly equivalent to what is in box 33.
There are two common themes to the recent rejections.
1. No Billing Provider NPI was sent on the claim, and the other is an invalid Billing Provider NPI. Some practices are not sending in an NPI that represents the business. When speaking to clients, most did not understand that it was even required, or that it applied to large organizations, not their single provider practice. Unfortunately there is always a Billing Provider. For a few special cases that Billing Provider is the physical doctor’s NPI. For most practices, there needs to be an NPI that represents the practice. The most common remedy for this situation is simply to add the right NPI number to the practice configuration. Few clients get hung up too long on this problem because of its easy solution.
2. More complex is the rejection where you have sent a billing provider NPI, but Medicare does not like it. What this means is the three computers involved, yours, the NPPES system, and Medicare’s did not all agree to the association. Most often the culprit is the new system in the middle, NPPES. The complexity comes in when you try to connect the dots. You know what Business NPI(s) you were given. You probably know what NPI was sent electronically, but what exactly did NPPES and Medicare not have in common? Here is where some detective work needs to occur. CMS has put out several “clues” for your detective work. You can search the CMS website for MedLearn matters related to NPI rejections. You will find that most rejection codes give you some hint as to what fact is broken on the NPPES database. Once the issue with the NPPES record is found and updated, most of our clients have been able to successfully pass the NPI edits. In essence you are changing the facts to fit the theory, just as Einstein explained.
So, are we there yet?
Medicare is a big hurdle for the industry. Prior to March 1st, we were aware of around 100 non-Medicare payers that had already switched to requiring NPI. More than likely if you are sending to Medicare, or any of the other payers who require NPI, you have connected the dots, and should experience few issues with May 23rd, 2008 – the last day any payer is supposed to be allowed to accept a claim without NPI. But there is one final major change to transactions that does pose a risk. At some point, in theory, on May 23rd, 2008, your claims will arrive at payers without any of the legacy ID numbers. What we don’t know today is how much of the recent success is attributable to the existence of the legacy ID numbers on the transactions. For Medicare that risk is thought to be low. For other insurance companies, the true test will be when they have nothing but NPI to associate back to you and your business. Keep communications open with all your major payers to insure your payments will continue to be sent once that last NPI hurdle is crossed.
Mark Martin has 22 years of experience with automating practices within the healthcare market. For the last 7 years, Mark has focused his efforts in the world of EDI, and is currently the Sr. Director of EDI Product Management at Sage Software. The Sage Software EDI team works with the industry to ensure Sage clients have options to comply with regulatory issues and the opportunity to leverage value added EDI transactions into operational efficiencies.
