Access Management Quarterly

Hospitals told: Don't delay in getting ready for NPIs

Risks include lost, delayed reimbursement

Failure to adequately prepare for the advent of the National Provider Identifier (NPI) will have a significant impact on provider reimbursement, says Beth Keith, CHAM, senior management consultant for ACS Healthcare Solutions.

Rejected claims, delayed reimbursement, and potentially lost reimbursement will result, Keith cautions, if providers don't take the appropriate steps.

All health care providers covered by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), whether individuals or organizations, must obtain an NPI for use in identifying themselves in HIPAA standard transactions, she says.

A 10-digit numeric identifier that does not expire or change, the NPI must be used exclusively by May 23, 2007, to identify covered health care providers in standard health care transactions by HIPAA-covered entities, such as providers completing electronic transactions, health care clearinghouses, and large health plans. Small health plans must use only the NPI by May 23, 2008.

The identifier is used to ensure that medical claims are processed in a timely manner and payments are made correctly.

Keith advises hospitals to get ready for the change by making sure the following things have been done:

  • NPI numbers have been obtained for all required providers;
  • Existing provider master files have been cleaned and corrected;
  • A crosswalk with NPI numbers and UPIN, payer identifiers, etc., for all providers has been mapped; and
  • Dual NPA numbers and existing provider numbers are ready for testing claims submission to Medicare fiscal intermediaries, clearinghouses, and electronic billing vendors from Oct. 2, 2006, through May 22, 2007.

The change affects providers' information technology systems as well as their reimbursement, Keith points out, in that current claims-processing systems must accommodate the NPI identifier—in addition to current payer identifiers— from now until May 23, 2007.

"Following this initial implementation date," she adds, "the system must be prepared to switch completely to the NPI number by May 23, 2008, when small payers are required to comply with the ruling."

To facilitate the conversion, Keith points out, some organizations have volunteered to assist their medical staff through their medical staff credentialing offices. By assisting the physicians in obtaining these identifiers, she notes, these facilities have the data available for their IT system, which ensures their own success during the transition period.

"If your organization has not been involved in assisting your physicians in obtaining this important identifier," Keith says, "you must obtain these numbers from each medical staff member, enter them into your IT system, and validate their presence on the claim forms as of May 23, 2007."

It's advisable to get the number several months in advance so testing can be done between provider and payer systems to prevent any potential loss in reimbursement, she emphasizes. Following this initial effort, Keith suggests, providers should get the identifier as part of their physician credentialing information process.