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NPI Impact on Health Care Providers -Business Impact of the Implementation of the NPI on Health Care Providers

Eleventh Annual HIPAA Summit / Second HIT SummitSeptember 7-9, 20053.05 Shared HIT/HIPAA Issues

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NPI Impact on Health Care ProvidersAgenda

Global IssuesBenefitsBusiness Issues

Provider-Specific Business IssuesOrganizational ProvidersIndividual Providers

AMA and Forrester Study ResultsNUCC Update

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NPI Impact on Health Care Providers –Global Issues

Benefits100% Portability (within United States)Provides for a unique identifier for all health care providersEliminates the occasional re-assignment of provider numbers en masse

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Benefits (continued)Greater standardization of provider identifier X12N, CMS-1450, CMS-1500, ADA, and DDE transactionsCovered providers / Eligible providers who enumerate, supports a single contact point for NPI dataPotential simplification of COB

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Benefits (continued) Potential simplification across disparate clinical and financial information systems –internal / externalClinical, RHIO, and EHR data benefits from single identifierSimplification of fraud and abuse, tracking of license revocation, and other criminal activities

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NPI Impact on Health Care Providers –Global Business Issues

Relationship ChangesLegacy Identifiers

Linked to the enrollment in a health planAssigned by health planFrequently identified service or location of service via embedded intelligenceLimited to claim submission and adjudication processOne Provider : Numerous identifiers per plan

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Relationship ChangesNational Provider Identifier

Assigned by single source at Federal level - NPPES EnumeratorUnique and assigned for life of providerPermanent Professional IdentityIndividual Providers : One NPIDoes not “auto-enroll” provider in plansNew: Covered ProviderDirect impact to other providers’ reimbursementCovered Providers: Civil Monetary Penalties for non-complianceMay be used for any legal purpose

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Review of state lawsIdentify any conflicts or supplemental requirements

Taxonomy codesIdentify any new plan requirements

State licensure issuesDetermine if there are any NPI-related requirements by state boards

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Implementation StepsAssemble implementation teamIdentify affected operational areasDevelop project planIdentify affected trading partners / business associatesContract ReviewAudit/Validate Provider Data (Internal)Determine application strategy

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Implementation Steps - continuedIdentify technology issues

Gap analyses – Comprehensive ReviewsNPITaxonomy

ReportsInternalExternalHistoric Reporting Issues

InterfacesDocument Imaging / Archival SystemsClinical ApplicationsFreestanding Databases

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Implementation Steps – continuedDetermine Subpart Strategy (Organizational Providers only)Determine taxonomy strategyDetermine NPI collection / validation strategyDefine disclosure / dissemination strategyDecide education and communication planDetermine testing and implementation strategies

Developed with each trading partner and business associate

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Implementation Steps – continuedDetermine transition strategies

Developed with each trading partner and business associate

Compliance Date vs. Implementation DatesDual Identifier use in X12N transactions

Regional InitiativesContinuity planning

Providers without NPIs in covered transactionsReferrals

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Access to Provider NPIsDisclosure is keyDisclosure required for use in standard transactionsDissemination

Many unknowns at this timeCMS committed to limiting NPPES access and protecting NPICMS will impose strict limitations for EFIOsregarding dissemination

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NPI Impact on Health Care Providers –Organizational Providers

Educate Administration / Senior LeadershipBusiness Processes

Revenue Cycle DepartmentsManaged CareMedical Staff CredentialingProvider EnrollmentMedical RecordsPractice ManagementDecision Support / Reimbursement AnalysisBusiness Development

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SubpartsNot a contractual issue; identifies the provider of service, not the serviceSeparately identifiable component of the larger organizationNOT a location identifierGranularity Issue

Go Fish

Communication and NegotiationTransaction-based Solutions

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Requirements for Organizational ProvidersObtain an NPI for itself and/or subpart(s)Use NPI to identify itself on standard transactions where required Disclose its NPI when requested to any entity needing the NPI for a standard transactionReport updates to NPS within 30 days of changeRequire Business Associates to use all NPIs appropriatelyComply with requirements for subpartsSecure NPIs from any entity when needed for a transaction

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Pharmacy Service ProvidersPharmacies and Pharmacists will need to apply if covered health care providerThe NCPDP transaction does not support dual identifiers. A plunge implementation strategy will have to be adopted for all pharmaciesNCPDP will apply to be an EFIONCPDP maintains information such as payment centers and pharmacy parent organizations as well as network affiliations in their database; the NPPES does not

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Pharmacy Service Providers – con’tDisclosure - Highest Risk with Enormous Volume

Long Term CareEffective October 1, 2005, the NPI may be used on the Minimum Data Set (MDS) to identify the facility

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Ambulance ServicesEnumeration will depend upon

Operational structureFreestandingMunicipalityCounty

How services are billedAmbulance ServiceProviderPlan Requirements (may change with NPI)

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NPI Impact on Health Care Providers –Covered Entities

The Application GapMust not overlook or under estimate impactNPI component of HIPAA TCS RuleAll health care providers are eligible; not all are requiredFederal enforcement limitedSituational requirementsApproaches being taken

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NPI Impact on Health Care Providers –Individual Providers

Business ProcessesFront DeskScheduling / RegistrationBilling / AppealsEnrollment

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NPI Impact on Health Care Providers –Individual Providers

RequirementsObtain an NPI for selfUse NPI to identify itself in required transactionsDisclose its NPI when requested to any entity needing the NPI for a standard transactionReport updates to NPS within 30 days of change (Example: Address Change)Require Business Associates to use all NPIs appropriatelySecure NPIs from any entity when needed for a standard transaction (Example: Referring Providers)

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NPI Impact on Health Care Providers –Individual Providers - Concerns

Security hazards – some physicians fear their personal data could be subject to identity theft, fraud or other abuseAccess to database data – businesses desiring to market products and services to physiciansAccess to NPPES – balanced access for providers and payers to obtain necessary data for referring/ordering physicians, etc.

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NPI Impact on Health Care ProvidersIndividual Providers - Concerns

Some physicians have had trouble with the Internet-based interface when applying for NPI Some physicians don’t want to use an NPI and believe that new numbers will cause confusion and bureaucratic hassles rather than reduce themSome physicians have threatened to retire rather than place their personal information at risk

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NPI Impact on Health Care ProvidersIndividual Providers - Concerns

Many providers have never heard about NPIAlthough only HIPAA mandates use of NPIs in electronic transactions:

NPI recommended for use in e-prescribing Clinical SystemsWill payers require NPIs on paper claim forms? Probably.

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NPI Impact on Health Care ProvidersKnown Barriers - Industry

Education and AwarenessWEDI White PapersWEDI NPI Outreach Initiative (NPOI)CMS Website and NPI ViewletNPPES WebsiteLack of information from constituent organizations

Complex Adjudication Systems / Practices and Dependencies on Existing Practices

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NPI Impact on Health Care ProvidersKnown Barriers - Industry

Limitations in Rule and EnforcementApplication Gap

Compliance Date BlindersPerception that the NPI’s use is limited to billingTime to Market Vendor Responses

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NPI Impact on Health Care ProvidersImpact Analysis

There are no silver bulletsStrategies are business need driven

Your OrganizationTrading PartnersBusiness Associates

Communication and NegotiationNPI is an industry issue

Reinforces need for Provider / Health Plan collaboration

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NPI Impact on Health Care Providers -Current Electronic Environment

The following survey information is from an AMA and Forrester study entitled “Physicians’ Use of Information Technology”

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NPI Impact on Health Care Providers –Physicians’ Electronic Claims Activity

88% of claims are submitted electronically47% submit claims directly to payers41% submit claims through a clearinghouse19% send claims to a billing service6% do not submit claims (patient submits claims)

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NPI Impact on Health Care Providers –Attachments for Physicians’ Claims

76% of physicians report that payers require attachments20% of their claims require attachments47% of attachments are “snail” mailed23% of attachments are faxed6% of attachments are sent electronically5% of attachments are sent by messenger2% of attachments are scanned images

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NPI Impact on Health Care Providers –Implementation of e-Prescribing

8.6% reported that their practice has implemented an electronic prescribing system, but only on a limited scale.11.7% reported that they have implemented an electronic prescribing system throughout the practice.

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NPI Impact on Health Care Providers –Implementation of e-Prescribing

14.2% reported that they have not implemented an electronic prescribing system, but have investigated and tested some systems.62.5% reported that they have not investigated an electronic prescribing system for their practice.

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NPI Impact on Health Care Providers –Physician Computer/Web Usage

0

10

20

30

40

50

60

70

80

90

100

1997 1999 2000 2001 2004

%

Computer Users Web Users

42% 41%

75%

70%

37%

20%

82%

78%

98%

95%

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NPI Impact on Health Care Providers –The NPI and the 1500 Paper Claim Form

HIPAA does not require the NPI on the 1500 paper claim formClaims are scanned into payers’ systems and the data on paper claims should be consistent with the data in electronic claimsThe current 1500 is not designed to carry the NPI The current form has not been updated for 15 years

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NPI Impact on Health Care Providers –The NPI and the 1500 Paper Claim Form

NUCC recommends use of NPI on paper formNUCC Members:

American Medical AssociationAmerican Association for Homecare State Medical Association American Academy of Physicians AssistantsCenters for Medicare and Medicaid Services -- Medicare Centers for Medicare and Medicaid Services -- Medicaid Medical Group Management Association National Association of State Medicaid Directors

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•NPI Impact on Health Care Providers –The NPI and the 1500 Paper Claim Form

NUCC – continuedBlue Cross and Blue Shield Association Alliance for Managed Care National Uniform Billing Committee America’s Health Insurance Plans Dental Content Committee ANSI ASC X12NHealth Level Seven Public Health Data Standards Consortium – state perspectivePublic Health Data Standards Consortium – federal perspective

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NPI Impact on Health Care ProvidersThe NPI and the 1500 Paper Claim Form

The NUCC proposed some changes to the 1500 paper claim form to accommodate the NPISurvey and comment period was conductedThe majority of the respondents agreed with the proposed changes

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NPI Impact on Health Care ProvidersSurvey Responses - Providers

Cleveland Clinic FoundationMayo ClinicAllina Hospitals and ClinicsChildren’s Hospitals and ClinicsFairview Hospital and Health Care ServicesHennepin County Medical CenterHennepin Faculty AssociatesPark Nicollet Health ServicesNorth Side Medical ClinicBayhealth Medical CenterCarolina Regional Cancer CenterRiver Crest Hospital

Susquehanna Health SystemHealthEast Care SystemSt. Mary’s/Duluth Clinic Health SystemUniversity of Minnesota PhysiciansUniversity of Minnesota School of DentistryUniversal Health ServicesUHS of Pennsylvania, Inc.Osceola County EMSTalbott Recovery CampusMediServ, Inc.

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NPI Impact on Health Care ProvidersSurvey Responses - Providers

Partners in Primary CareDigestive Health ManagementRichmond Radiologists, Inc.Radiology Associates of San Antonio, PASouth Texas Radiology Group, PARadiology Associates of Muncie, Inc.Metropolitan Pain Management Consultants, Inc.Endocrinology Associates of HoustonHappyland Pediatrics10 Solo Practitioners

Athens Regional Home InfusionInfusion PartnersGreenwood Genetic CenterFond du Lac Human Services DivisionJefferson County Human ServicesRehab Alliance Physical Therapy and FitnessTherapy in MotionArchibold High Tech Services, Inc.EyeMart ExpressLaboratory Corporation of America

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NPI Impact on Health Care ProvidersSurvey Responses – Health Plans

CMSNoridian Administrative Sevices, LLC – Medicare Part AWisconsin Physician Services –Medicare Part BVirginia MedicaidState of Idaho – MedicaidCalifornia MedicaidElectronic Data SystemsDepartment of Health and HospitalsDepartment of Health and Social ServicesDepartment of Veterans Affairs-HACUnitedHealth GroupHighmark, Inc.

Blue Cross Blue Shield of AlabamaBlue Cross Blue Shield of FloridaBlue Cross Blue Shield of MinnesotaDelta Dental Plan of MinnesotaHealthPartnersMedica Health PlanPreferred OneUCare MinnesotaMetropolitan Health PlanACS Benefit Services, IncThe Regence GroupSagamore Health NetworkWisconsin Physician Services Insurance CorporationExcellus Health Plan

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NPI Impact on Health Care ProvidersSurvey Responses - Vendors

McKessonSiemens Medical Solutions Health Services CorporationMisys Healthcare SystemsMedata, Inc.MEDTRON SoftwarePDSE-Z BIS, Inc.Accu-Med ServicesMedispec Management Services, Inc.

Allwin DataPer-se Technologies, Inc.Clinix MISAnexix, Inc.Physician’s Computer CompanyElectronic Data SystemsTele Comm Computer Systems, Inc.QuadraMedSpecialized Clinical Services

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NPI Impact on Health Care ProvidersSurvey Responses - Others

CHAMPUS/TRICAREAmerican Urological AssociationAmerican College of PhysiciansAmerican Association of Oral and Maxillofacial SurgeonsAmerican Psychological AssociationNational Association of Social WorkersAmerican Health Information Management AssociationAmerican Association of Healthcare Administrative ManagementIngenixConnolly Strategies & InitiativesNextGen Health Information SystemSaltzer Medical Group

Minnesota Hospital AssociationMinnesota Medical AssociationMinnesota Medical Group Management AssociationMinnesota Pharmacists AssociationMinnesota Dental AssociationMinnesota Department of HealthMinnesota Department of Human ServicesMinnesota Department of Labor and IndustryMinnesota Uniform Billing CommitteeMidwest Center for HIPAA EducationHCPCS CommitteeHealth Care Payer and Provider Advisory Council

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NPI Impact on Health Care ProvidersSurvey – Some Provider Issues Identified

Managed care contracts could be an issuePossibly having to maintain use of old provider numbers from health plans as well as use of newer NPI and the “mapping” of this information will create a hardshipNew software updateThe proposed changes are an unnecessary burden to providers, billers, and payers of medical servicesMajor expense in either buying a new computer system or we would have to manually type every claim

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NPI Impact on Health Care ProvidersThe NPI on the 1500 Paper Claim Form

NUCC approved the claim form for use in 2007Next step – OMB to review and approve for CMS

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Thank You

Jean P. NarcisiNational Uniform Claim Committee Chair

Michael A. ApfelTruman Medical CentersKansas City, Missouri

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