Consensus getting closer on provider ID rules

Final rule due by end of year

Final agreement on a new standard for assigning new provider numbers to all providers (physicians, hospitals, nursing homes, etc.) has come closer after a meeting of the Workgroup for Electronic Data Interchange (WEDI) in Washington, DC.

The group is attempting to develop a consensus for use of a single provider identification number to be used when processing electronic claims, plus a universal standard format for these electronic claims.

As called for in the Health Insurance Portability and Accountability Act of 1996, the Department of Health and Human Services has issued a proposed set of regulations for implementing the new system of provider ID numbers and the national provider system (NPS) of standardized electronic claims. WEDI was created as a forum for industry and government officials to informally hash out differences and come to consensus on the best way to implement the new electronic payment system.

"The aim of these efforts is to help move more providers from paper to electronic claims submission," says Nancy-Ann DeParle, administrator of the Health Care Financing Administration (HCFA). HCFA estimates the electronic-based claims system will save the agency some $1.5 billion in processing costs over five years once the system is fully implemented. As part of a goal of pushing more providers to convert to electronic processing, HCFA also is asking permission from Congress to start charging a $1 processing fee on every paper claim submitted by physicians.

Stewart Streimer, the HCFA official charged with coordinating the installation of the agency’s new provider ID and electronic payment system, told a January WEDI meeting that the agency has completed a draft of its proposed rule-making on electronic claims attachments, which the agency hopes to release this spring. However, additional proposed rules covering such topics as standards for electronic medical records, health data confidentiality, and the national patient identifier are not likely to be published before the year 2000.

Three sets of proposed rules directly affecting providers already have been released: Standards for Electronic Transactions, National Provider Identifier (NPI), and Security and Electronic Signature Standards. Streimer hopes to have these rules in final form by the end of the year.

"Once a final rule is published, Congress has 60 days to comment, extend the effective date, or even repeal the proposal entirely," says Pat Smith, a government affairs representative with the Washington, DC, office of the Medical Group Management Association. Official implementation would take place 24 months after the final rule’s effective date.

Under the January working group’s recommendations:

• Every provider will receive an NPI.
• Providers who bill Medicare will automatically be enumerated first; others will have to apply for an NPI.
• Organizations will receive separate NPIs.
• There would be no fines for noncompliance until the system is fully implemented and tested.
• All entities billing Medicare would be enumerated, not just physicians.

Under the three levels of clearance to NPS information constructed by the working group, enumerators would have access to all NPS-related information. Meanwhile, providers, payers, and clearinghouses would be given restricted access to information for which they can justify a "legitimate business use." The general public, however, would only have very restricted access to limited data elements.

Other recommendations include:


— No fees will be charged to place providers or update their information in the NPS.
— Federal funds should be used to create the NPS, with user fees charged to those accessing the data to cover ongoing maintenance costs.
— Contrary to HCFA’s proposed rule, the meeting recommended that providers be enumerated through a single federal registry, not a combination of federal and state registries.


Concerned that HCFA’s proposed NPS would capture much more information about providers than is necessary for regular business purposes, the meeting recommended that several data elements — such as educational information and race — be deleted.

To protect provider confidentiality, WEDI members also recommended that no fraud and abuse or other legal-related information be included in the NPS. "This is a politically sensitive subject which is going to require more discussions between HCFA and provider groups over the need for — and type of — provider-related fraud and abuse information contained in the final rule," says a lobbyist for one health care group.

WEDI will meet again in March to vote officially on these recommendations.