Veterans Health Administration 11th Annual HIPAA Summit

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Veterans Health Administration11th Annual HIPAA
Summit NPI Update

• C. David Mc Daniel
• Deputy Director, Business Development
• Michael Wierzbicki
• Standard Identifiers Component Liaison
• September 9, 2005

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The National Provider Identifier

• A standard, unique, 10-position, numeric
  identifier
• Maintained by Centers for Medicare and Medicaid
  Services (CMS)
• Required in HIPAA-standard electronic health care
  transactions
• Intended to universally identify trained,
  licensed providers of health care services and
  supplies
• Individuals (i.e. doctors and other health care
  practitioners)
• Organizations (e.g. hospitals and nursing homes)

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The National Provider Identifier

• Deadline By May 23, 2007, HIPAA "covered
  entities" must use NPIs on all HIPAA-standard
  electronic transactions
• Therefore, NPIs are required for
• All billable health care practitioners providing
  health care services to VHA (a HIPAA-covered
  entity)
• VHA organizational providers

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Implementing the NPI

• The Department of Health and Human Services (HHS)
  contracted with an organization, known as the
  Enumerator, that receives and processes NPI
  applications by
• Using the National Plan and Provider Enumeration
  System (NPPES) to uniquely identify each health
  care provider
• Answering questions about NPI applications,
  assignments, and information updates
• Collecting information, via applications and
  updates, to maintain the NPPES database (which
  contains NPIs and provider information).

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VHAs Implementation of the NPI

• What is VHA doing about the NPI?
• Established an NPI Workgroup consisting of
  representative from VHA provider and health plan
  business lines
• Brokered relationships with other federal
  agencies
• Spreading the word to the provider community
• Actively participating in the Workgroup for
  Electronic Data Interchange (WEDI) NPI Policy
  Advisory Group (PAG) and
• Preparing for bulk enumeration (enumeration is
  the process by which providers are assigned NPIs).

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Four Critical Processes Now

• Enumeration of Individual Providers

• Enumeration of Organizational Providers

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Four Critical Processes Now

• Preparation of the Revenue Cycle

• Preparation of Credentialing and Privileging to
  collect and maintain NPIs

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Enumeration of Individual Providers
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• Awareness Support
• Distribution Verification
• Authorization, Application, Enumeration
• Re-distribution Implementation

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Enumeration of Providers

• Designated the VHA Chief Business Office (CBO) as
  the lead in ensuring that providers can apply
  for, and receive, NPIs in bulk.
• Credentialing Privileging to maintain
  enumeration
• Worked with VHAs credentialing privileging
  service on a process to receive the necessary
  provider information and send it to the
  Enumerator
• Received first pass of data in a database, which
  was created for the compilation of providers NPI
  application information
• Will refresh this data closer to the bulk
  distribution process
• Strategized about educating VHA providers and
  developed NPI educational materials for the field
• Participated in CMS NPI test program
• Identification of billable providers required to
  obtain an NPI (primarily at medical center and
  clinic levels, but some exist at lower levels)
• Met with VHAs office of acquisitions to discuss
  how the NPI will affect contracting (i.e.,
  changes to contracting requirements)
• Engaged union involvement to ensure that no
  difficulties were posed by VHAs requirement for
  providers to obtain NPIs

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Enumeration of Organizational Providers
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• Identification of level of granularity for
  sub-parts
• Reconciliation with the way in which health care
  facilities are numbered (VHA-specific and federal
  tax ID number, etc)
• Anticipation of maintaining NPI application data
  in a dynamic environment

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Enumeration of Organizational Providers (contd)

• HIPAA PMO to maintain enumeration of
  organizational providers
• In preparation for enumeration, developed
  database for storing organizational provider
  information
• Currently accomplished at the medical center and
  community clinic levels
• Verifying the appropriate level of enumeration of
  VHA subparts

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162 VAMCs (per VISN breakdown)
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681 CBOCs (per VISN breakdown)
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852 Sites (per VISN breakdown)
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Preparation of Revenue Cycle
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• Identification of system and software changes
  needed
• Identification of business process changes needed
• Internal testing

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Preparation of EDI Revenue Systems

• Project manager identified for Electronic Data
  Interchange (EDI) Revenue Systems processes, not
  just internal billing
• Preliminary plan to address the changes that are
  being defined
• Expect to be testing these systems with payers by
  summer 2006
• Anticipate payers will need time to work through
  back-end issues with elimination of current
  provider numbers
• On target for a May 2007 implementation of NPIs
  within the billing processes

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VHA Revenue Cycle
Pre-registration Treatment
Generate Receive
Post Intake
Claims AR
Payment Revenue
CIDC charge capture
e-Claims Plus e-Pharmacy Claims Faster payment,
Drug Utilization Review (DUR)
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Preparation of Credentialing and Privileging to
collect and maintain NPI
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• Identification of necessary system and software
  changes
• Adding fields for the NPI
• Not adding taxonomy codes
• Identification of necessary business process
  changes
• Internal testing

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Scope of Providers

• Licensed independent providers
• Per data gathered 8/18/05 from Credentialing and
  Human Resources systems
• 81,649 total providers have begun the
  credentialing process
• 53,466 active providers at some point in the
  credentialing process
• 46,549 appointed providers, credentialing
  completed

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Two More Critical Processes

• Identifying and communicating with trading
  partners
• Canvass VHA payer community to understand its
  needs
• Assess contract terms to validate NPI
  organizational outline
• Communicate with payer partners on phased
  (legacy, dual, and NPI-only) compliance approaches

• Software development and NPI Implementation that
  will not negatively impact the revenue cycle
• Gather requirements
• Design software
• Develop systems
• Conduct internal testing of interfacing systems
  and external testing with clearinghouse and payer
  partners

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Other NPI Preparation

• Drafted NPI official guidance in the form of a
  directive and handbook
• Discussed the NPI on appropriate national VHA
  calls
• Worked with Human Resources to obtain data to be
  used in bulk enumeration file
• Developed internal web site to compile and
  distribute providers NPI application information
  in preparation for NPI bulk enumeration
• Disseminated all approved educational material to
  the field via the VHA HIPAA PMO web site

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Expected Issues to Address

• Complexity of impact to organizational systems
  and business processes will be great
• Volume of providers to enumerate is significant
• Changes to credentialing and privileging process
  and systems to accommodate NPI must be completed
• Union and contracting changes to accommodate a
  requirement to have, maintain, and use an NPI
  will require negotiations (both internally and
  externally)
• Some trading partner limitations and
  complications remain to be fully understood and
  factored into the overall implementation strategy

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VHA Implementation Issues

• How much effort will be required to integrate the
  NPI into existing systems?
• Bulk enumerating individual and organizational
  providers with CMS
• Will CMS system be able to handle VHAs bulk
  load?
• How far down into VAs organization do we
  enumerate organizational providers?
• Billing or pay-to provider versus service
  provider
• How do we effectively spread the word about the
  NPI to all affected employees?

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Unexpected Issues to Address

• These factors add to the anticipated complexity
  of the changes necessary for migrating from
  legacy numbering systems
• System of Records issues related to Privacy Act
  requirements
• Variables in provider types (licensed VS.
  non-licensed billable VS. non-billable
  interested in bulk enumeration VS. not
  interested etc.)
• Communication challenges reaching all providers
  who need to hear about the NPI
• Misinformation in the industry

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Misinformation Example
Source Internal Medicine News, July 15, 2005.
The requirement could mean that some physicians
who are part of group practices and other
arrangements would have multiple NPI numbers.
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Industry Call to Action

• Begin dialog NOW (or months ago)
• Partnerships with provider and plan groups to
  discuss each others needs and anticipated
  problems
• Seek common ground to address some of the largest
  issues
• Transition from legacy numbering systems
• Testing, scheduling, and EDI partnerships
• Maintaining revenue flow between plans and
  providers
• Speaking the same language, common interpretation
  of the Rule and not bogging down into minutia
• Learn from the industrys mistakes in EDI

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Spirited Discussion