If you are confused about implementation of the new National Provider Identifier (NPI), you are not alone. Government agencies have admitted that there are still many hurdles to full implementation by the deadline in May 2007, not the least of which is that “providers” seem to be reluctant to apply until they have a better understanding as to how the NPI will be used. For example, more than 1,000 telephone lines weren’t enough to handle all of the questions during a phone roundtable held by CMS in September 2006.

So the government has decided to provide more training kits for you that they refer to as “NPI 101.” But AAPS is concerned that even these training tools won’t answer all of your questions. Further, because some of the regulations are yet to be written, some questions simply have no answers yet. Those are of great concern to us, and we suggest that you demand answers from your contracted insurance companies and the government. We expect to issue more guidance, so contact us with your concerns and questions. Unanswered questions at this time include:

• Will the government be able to track all of my accounts receivable and/or billings using my NPI?

• Will other government agencies, such as the IRS, have access to information associated with my NPI?

• Will a patient need an NPI from his doctor if he wants to file a direct claim with his insurance company?

• What kind of security can I expect to protect my NPI? If my identity is stolen, couldn’t it be used to file false claims? Will I be held responsible or prosecuted? Will errors be corrected expeditiously?

• Will labs and hospitals require a NPI for every order? Will the NPI be used to monitor my treatments to impose pay-for-performance? Will private insurers require an NPI on paper claims submitted by doctors?

Overview:

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated that the Secretary of Health and Human Services adopt a standard unique health identifier for health care providers. On January 23, 2004, the Secretary published a Final Rule that adopted the National Provider Identifier (NPI) as this identifier.

All HIPAA-covered health care providers, whether they are individuals or organizations, must obtain an NPI to use to identify themselves in HIPAA standard transactions. Once enumerated, a provider’s NPI will not change. The NPI remains with the provider regardless of job or location changes.

HIPAA-covered entities, such as providers completing electronic transactions, health care clearinghouses, and large health plans, must use only the NPI to identify covered health care providers in standard transactions by May 23, 2007. Small health plans must use only the NPI by May 23, 2008.

When applying for your NPI, CMS urges you to include your legacy identifiers, not only for Medicare but for all payers. If reporting a Medicaid number, include the associated State name. This information is critical for payers in the development of “crosswalks” to aid in the transition to the NPI.

Specific Questions:

1. Am I required to get an NPI to practice medicine?
NO. The rule states that HIPAA-covered entities, as defined at 45 C.F.R. § 160.103, are required to obtain an NPI.

2. But what if I’ve opted for the “Country Doctor” exclusion established by AAPS that allows me to remain a non-covered entity under HIPAA, and I have no third-party contracts?
You may not need an NPI if you are a non-covered entity, and take absolutely no third-party payment.

3. What if I do see Medicare patients and file only paper claims (qualifying me as a HIPAA non-covered entity)?
This is the one exception to the HIPAA non-covered entity provision for the NPI. The rules require that any provider who files claims with Medicare, INCLUDING PAPER CLAIMS, must use an NPI. That applies whether you are participating or non-participating.

4. So the only way I can avoid getting and using an NPI is to be a HIPAA non-covered entity AND opt out of Medicare?
Yes. But consider the advantages of declaring your independence. You will protect yourself from the possibility of prosecution if your compliance is imperfect. (Punishments of up to $250,000 fines and 10 years in prison.) Otherwise, you could be prosecuted for failing to meet the letter of the law—some 3,000 pages—even if no patient records are compromised.

You’ll protect your patients from having their private records entered into a nation-wide computer data base, potentially accessible by thousands of private and public bureaucrats, law enforcement agencies, employers, and hackers. You’ll save up to tens of thousands of dollars in compliance efforts.

And finally, you keep the practice of medicine free from the straitjacket of working through a recipe book of 200,000 government-imposed codes and almost 200,000 pages of Medicare rules.

5. So what’s the purpose of the NPI?
According to CMS: “The NPI is one of the steps that CMS is taking to improve electronic transactions for health care. National standards for electronic health care transactions encourage electronic commerce in the health care industry and simplify the processes involved to reduce the administrative burdens on health care providers.” As stated above, AAPS is concerned that the NPI will be instrumental in implementation of pay-for-performance.

6. Will I keep my old identification numbers?
Yes and no. The NPI will replace all identifiers you are using now for transactions. However, health care provider identification numbers other than the NPI may continue to be used in the internal processes and files of health plans or health care clearinghouses if they wish to continue to use those identification numbers in those internal processes and files. So you may end up having to use all of your numbers. So much for administrative simplification.

7. What’s the deadline for using the NPI?
Medicare, Medicaid, large private insurance issuers, and health care clearinghouses must accept and use NPIs in standard transactions by May 23, 20007. Small health plans have until May 23, 2008.

8. Any other deadlines?
Yes. Medicare will require the use of a revised Form CMS-1500 by February 1, 2007. These forms are available now.

9. So can I wait until the deadline to apply and still be in compliance?
You may be able to wait to apply. The rule only requires that you “obtain” an NPI by May 23, 2007. But you won’t be able to submit any claims to large health plans, Medicare, Medicaid, or clearinghouses until your have your number.

10. After the May 2007 deadline, will I be able to use my old “legacy” numbers?
The official answer is “No.”

However, on October 11, 2006, industry representatives urged HHS to allow the use of legacy numbers in addition to the NPI for a minimum of six months past the deadline to allow for ease of transition. They fear that because so few providers have been “enumerated” at this point, there will be tremendous problems in bringing systems into compliance by the May 2006 deadline. Some have expressed concerns that they expect long delays in payments to providers. At a recent forum on Medicaid, about one-third of states admitted that they do NOT expect to be ready to process only NPIs for payments.

11. What is the NPPES? What is the “Enumerator?”
NPPES is the National Plan and Provider Enumeration System. The Department of Health and Human Services selected Fox Systems, Inc., as the Enumerator. It will process applications, assign numbers, resolve issues related to applications, and will operate a call center and an electronic mailbox for questions about obtaining NPIs.

12. How do I apply?
There are three ways to become “enumerated”:

• APPLY ONLINE at https://nppes.cms.hhs.gov

• MAIL APPLICATION: You may prepare a paper application and send it to the Enumerator. Download the application at the URL above or call 1-800-465-3203.

• THIRD-PARTY APPLICATION: With your permission, a professional organization or your employer can submit an electronic file with information along with others.

14. How much does it cost to apply?
There is no charge to apply, nor is there an annual fee.

15. What’s the format of the number?
The NPI is all numeric and has 10 positions: the first 9 positions are the identifier and the last position is a check digit. The check digit helps detect invalid NPIs.

16. Do I have to notify the Enumerator if I move or change jobs?
Yes, covered entities must file notice of any changes to information on their application within 30 days of the change. Non-covered entities are “encouraged” to do so as well.

17. Will change the way I get paid or how long it takes to get paid?
It won’t change the way you get paid, but you should expect delays in payments during the “shakedown” period. Industry experts testified to HHS that delays of 9 weeks or more can be expected.

18. What’s a primary vs. secondary provider?
Providers are categorized as either “primary” or “secondary” providers: Primary providers include billing, pay-to, rendering, or performing providers. Secondary providers include supervising physicians, operating physicians, referring providers, etc.

19. How do I update my billing software?
It is your responsibility to contact your software vendor to get updates that will accommodate the NPI.

20. Can I use my NPI before May 23, 2007? Should I use both legacy numbers and my NPI before then?
Yes. You may use your NPI now. However, most payers don’t have their systems ready to go yet, so you will probably have to use both your NPI and your old legacy numbers. Payers should notify you when they are ready for the NPI alone.

21. What happens if I don’t have an NPI?
If you submit a claim that requires an NPI after the May deadline, your claim will be rejected.

The information above represents the analysis of the Association of American Physicians and Surgeons for public discussion and debate. This may not be construed as legal advice. Please consult an attorney for legal advice.

Resources used in preparation of this paper:

• Letter from CMS Director, May 6, 2005

• CMS website www.cms.hhs.gov/hipaa/hipaa2       www.cms.hhs.gov/NationalProvIdentStand

• National Provider Identifier Regulation (Federal Register, 1/23/04)

• Health Insurance Portability and Accountability Act (45 C.F.R. § 160.103)

• National Committee on Vital and Health Statistics www.ncvhs.hhs.gov