Medical Economics Feature - August 2008
Tex Med. 2008;104(8):29-31.
By Ken Ortolon
When the U.S. Centers for Medicare & Medicaid Services (CMS) earlier this year rejected requests to delay implementation of the national provider identifier (NPI) for another six months, CMS said both it and the nation were ready to move forward with the NPI.
It appears CMS was wrong.
Medicare and other health plan payers saw a substantial spike in rejected claims immediately after CMS began requiring physicians and other health care professionals to use the NPI as the only provider identifier on all claims filed as of May 23.
Physician offices, health claims clearinghouses, Medicare carriers, and others say there have been numerous problems with the NPI conversion. Some physicians are seeing large numbers of claims kicked back, while Medicare carriers and commercial health plans are having trouble matching the new NPIs with so-called "legacy" numbers in their enrollment data or physician contracts. That means those payers are having trouble determining how to pay physicians, hospitals, and other providers.
Still, officials with TrailBlazer Health Enterprises , the Texas Medicare carrier, say the overall number of claim rejections here since implementation of the NPI-only rule has been relatively small. And they and others in the claims-processing business are working out the kinks in the new system.
On the first day of implementation of the new NPI-only rule, Modern Healthcare Online reported that Medicare claim rejections had jumped fourfold, from 6 percent to 24 percent; Medicaid rejections had increased sixfold, from 4 percent to 26 percent; and rejections by Blue Cross and Blue Shield plans had doubled.
A week later, Modern Healthcare reported that daily Medicare claim rejections were still running at 25 percent and Medicaid was up to 37 percent.
"The claim rejections spiked after the 23rd, and there are a number of reasons why that happened," said Martin Jensen, chief operating officer and chief analyst at Healthcare IT Transition Group, a think tank and consulting firm that helps medical organizations implement health information technology. He says much of the problem was caused by "Medicare imposing some very strict edits, not just about sending your own NPI and not sending any other identifiers, but also for any other provider that appears on your claim, like a referring physician, an ordering physician, an assistant surgeon, or any of the variety of other providers that might appear on the claim. That was a completely untested data stream."
Barbara Harvey, vice president for program integrity at TrailBlazer, says her company did see a spike in rejections, but she disputes Modern Healthcare 's numbers.
"The first day or two, there were quite a few [rejections] simply because people didn't realize you can't have the legacy number on there," Ms. Harvey said. "So we got the claims with the legacy and the NPI. That was very quickly fixed either by the physician or the clearinghouses."
Some of the early problems also stemmed from some physicians' failure to share their NPI with other doctors, hospitals, ambulatory surgical centers, and others. If a treating physician did not know the NPI of the referring physician, for example, he or she might leave that field blank on the claim form or use the legacy number. That could cause the claim to be kicked back.
Ms. Harvey says Medicare claim rejections in Texas are averaging less than 0.5 percent per day. Texas Medical Association officials, however, say that the TrailBlazer figures may not include claims kicked back by the clearinghouses that never reach TrailBlazer.
Mr. Jensen, meanwhile, says even the numbers reported by Modern Healthcare may be an understatement of the problem.
"That's bad, but those numbers could be understatements because when claims quit going through, the natural thing for the biller to do is to quit sending them," he said. "There may be an unexpressed backlog of unfulfilled claims."
Stuck in the Crosswalk
Ms. Harvey says the issue with the greatest impact on physicians right now, at least as far as Medicare is concerned, involves physicians who had multiple provider transaction access numbers, or PTANs, but now have only one NPI. When those physicians' claims reach TrailBlazer, it doesn't know which PTAN to match to the new NPI, which delays claim processing.
If TrailBlazer can't match the NPI to a PTAN - one of several types of legacy numbers - the company will ask the physician which PTAN he or she wants to use. "It's not a huge number of providers," Ms. Harvey said. "But if you happen to be one of those providers who are getting them [letters], you're getting a lot."
Physicians might have more than one PTAN if they practiced in more than one location, she adds.
Ms Harvey says physicians with this problem have a couple of options. They can select a preferred PTAN and ask TrailBlazer to match their NPI to that PTAN for all claims. Or, they can combine their old PTANs into one number.
"That's a little more problematic because it involves filling out enrollment forms and working them through the enrollment process," she said. TrailBlazer, however, has people expediting those applications, she says.
Mr. Jensen says physicians and other health care professionals also have problems with Medicare if the legal business name associated with their NPI does not match the legal business name on Internal Revenue Service (IRS) records or their tax identification number.
Medicare advises them to change their legal business name in their NPI records to match that with the IRS, but Mr. Jensen says that may not solve the problem.
"If you change the legal business name on your NPPES [National Plan and Provider Enumeration System] record to match what they think it ought to be according to an IRS record somewhere else, you could still run into problems with Medicare," he said. That's because the legal business name "is one of the primary values that it looks at to match your NPI to all of its various old Medicare IDs."
NPPES is the repository holding NPI numbers.
Where's the Support?
TMA's Payment Advocacy Department staff has received several other types of complaints from physician offices since the NPI was required. It appears that at least one practice management software vendor has chosen not to update its software to accommodate the NPI-only rule and is leaving it up to clearinghouses to scrub old legacy numbers off of claims before transmitting them to the payers.
Also, some clearinghouses apparently are waiting for the payers to tell them how to handle claims that include the legacy numbers. Mr. Jensen says some private payers accept claims with legacy numbers, while others don't.
Jan A Ream, office manager for Austin Internal Medicine Associates, says she is getting a lot of warning letters from Blue Cross and Blue Shield of Texas about old legacy numbers still being included on their claims. She's frustrated trying to determine whether the problem lies with her software vendor, the clearinghouse, or Blue Cross, but if she can't fix the problem, she's afraid Blue Cross eventually will start denying her claims. She says her clearinghouse is removing those numbers only if the payer asks it to do so and has not received such instructions from Blue Cross.
Officials with the clearinghouse Availity, LLC, say they saw a spike in NPI-related issues right after the May 23 implementation date, but those problems waned over the intervening few weeks.
Mary Ann Orenchuk, Availity vice president for professional services, says 28 percent of their submitters initially experienced NPI problems. That was down to about 8 percent in mid-June.
"Most of the folks knew it was coming but weren't quite ready for whatever reason," she added. "It drove a lot of call center volume."
Ms. Orenchuk says Availity worked closely with payers as they decided how to address NPI issues, and the clearinghouse has "flexibility built into our system" to allow payers to decide what level of NPI compliance they will require.
Availity has information on its Web site showing the NPI readiness of health plan payers with whom it does business.
Ms. Harvey also says TrailBlazer has a special team working on NPI issues to ensure that problems are addressed on an expedited basis.
TMA officials say some NPI issues may continue for some time because the problems are not consistent from one physician to the next. That means issues must be resolved on a physician-by-physician basis.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
TMA Web Site Answers Your NPI Questions
With the national provider identifier (NPI) requirement now in effect, it is important to have the facts. TMA's NPI Resource Center has the information about the NPI that you need.
Among the information you'll find there is how to use the NPI Look-up Tool and how to add your NPI to TMA's NPI database to make the business end of your practice run smoothly.
Federal rules require you to share your NPI with contracted health plans, physicians with whom you make or receive referrals, and other entities with which you do business.
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