Confusion surrounds new national doctor ID number

The government and private payers still have to iron out a lot of details before the number will be more boon than burden.

By Joel B. Finkelstein — Posted Dec. 13, 2004

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Physicians will someday be able to use one identification number to fill out all their claim forms, but there is a long road before that goal comes to fruition.

Starting May 23, 2005, physicians can submit an application to the Centers for Medicare & Medicaid Services to receive their own National Provider Identifier. That single ID number will eventually replace all other identifiers that physicians use in reimbursement and other transactions with private payers, clearinghouses and the government.

The 10-digit NPI was established under the Administrative Simplification Compliance Act and is essentially the next phase in the government's effort to move the medical community toward a national standard for electronic transactions as part of the Health Insurance Portability and Accountability Act.

While the May deadline is fast approaching, it will take another two years from that date before health plans are required to start using the NPIs. Still, there is some concern that even two years is not long enough.

"Our biggest fear is that the providers who need the NPI will not get it in time," said Richard Landen, director of electronic standards for the BlueCross BlueShield Assn.

Physicians without an NPI at the end of that two-year period could face delayed or rejected claims.

While CMS and other organizations will be working hard to get that message out to all physicians, experience with previous HIPAA standards suggests that this could prove a difficult task. Outreach has fallen short in the past, leaving many physicians out of the loop.

Here comes the paperwork

For those physicians who do get the message, groups such as the American Medical Association and the National Uniform Claim Committee are concerned about the confusion in filling out the NPI application.

For example, the application in its current form requests several other physician identifiers, such as Drug Enforcement Administration and Medicaid billing numbers. But detailed instructions that accompany the form seem to suggest that those numbers are not required.

"It is confusing as to whether or not providing a DEA number, or other numbers, is optional," AMA Executive Vice President Michael D. Maves, MD, wrote in a comment letter to CMS. "In addition, there is an implication that failure to provide those numbers may result in a cessation of payment."

Dr. Maves goes on to say that the DEA number should be used only for prescribing purposes, not for verifying a physician's identity.

The NUCC notes in a comment letter on the form that the application appears to link taxonomy codes, which signify a physician's specialty based on a national standard, with license numbers, which are state-based. Variations in how states define specialists could cause potential mismatches that erroneously invalidate an application.

CMS is currently in the process of reviewing such comments and still can revise the application before it goes live, although officials said the form was pretty well settled before the comment period ended.

Some of the confusion generated by these details could be avoided if CMS allows medical societies or other organizations to provide bulk data on their physician members to the agency. That would avoid having each physician apply for an NPI individually.

This also could help prevent a lot of the data-entry errors inherent in a new database, said Robert Tennant, senior policy adviser for the Medical Group Management Assn.

CMS officials said they were open to this approach but expected such organizations to come to them, rather than having the agency solicit those data. So far, no organization has stepped forward, and experts said it was unclear whether groups that have appropriate databases would be willing to provide them for free.

However it gets there, once the information on physicians starts rolling in, it will be used to populate a brand new database, officially known as the National Plan and Provider Enumeration System. The system is being created by Canadian information technology company CGI.

No one from CGI was available for comment, but CMS officials said the system should be up and running in time to accept applications in May. If all goes according to plan, the system will allow physicians to enter their information directly into the database via an online NPI application.

If everything does not go according to plan, CMS will have an intermediary company create the online application process. The agency is currently seeking to hire such a company, which would be responsible for handling paper applications and manning telephone banks, but also would handle electronic applications if it became necessary.

Making it work

While all of these concerns are not insubstantial, "getting the number is the easy part," Tennant said.

Physicians who apply for and get their NPIs this spring can start putting them in their claim forms right away. But they will likely need to use the new number in addition to whatever identifiers they are already using for each individual payer until 2007.

The process of switching from the current system of multiple identifiers will not be simple or cheap for Medicare, the Blues or any other health plan. It's expected that many plans will use those two years to make the transition, experts said. Small plans have three years to achieve compliance.

The payers face many of their own obstacles in working out the mechanics of using only the NPI, said BlueCross BlueShield's Landen.

For instance, physicians might have two or more contracts with the same health plan and as a result have multiple identifying numbers with that one payer. Switching to the one-number system forces the plan to devise some other way to identify which contract applies for each situation.

Companies are just now beginning the process of analyzing their business processes to determine what steps they need to take in coming into compliance with the NPI requirements. They are also waiting on CMS for final specifications on the database on which they will also have to rely.

There are still a lot of logistical problems ahead, Tennant said.

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National provider identifier: Who, what, when

  • National Provider Identifiers, or NPIs, will be used in the future to identify physicians and others covered under the HIPAA statute.
  • Physicians will receive one NPI, which eventually will replace all other identifiers used in reimbursement of claims and other transactions with private payers, clearinghouses and the government.
  • Physicians can begin applying for NPIs from the Centers for Medicare & Medicaid Services as of May 23, 2005.
  • Most health plans must start using NPIs no later than May 23, 2007. Small plans have an extra year to start using them.

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What it will cost

CMS estimates that filling out an NPI application should take physicians or their staffs about 20 minutes. Physicians will have two years, after the launch on May 23, 2005, to apply and receive their numbers. The agency also estimates that each year about 13% of ID holders will need to update their information in the database. Impact for the entire health care community:

Hours Cost
2007 442,728 $6,089,192
2008 444,644 $6,360,111
2009 63,358 $942,568
2010 64,342 $993,135
2011 65,345 $1,051,246

Note: CMS assumes that NPIs will not be required before 2007.

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