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NPI Readiness, Risk Management and Contingency Planning The Day After May 23, 2007

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Institute for HIPAA/HIT Education and Research. Definition of Terms: ... Handling crossover/COB claims with other plans. NPI Contingencies - Payers. Hardest position: ... – PowerPoint PPT presentation

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Title: NPI Readiness, Risk Management and Contingency Planning The Day After May 23, 2007


1
NPI Readiness, Risk Management and Contingency
Planning The Day After May 23, 2007
  • Presented at the
  • HIPAA COW Spring 2007 Conference
  • Oconomowoc, WI March 30, 2007
  • Walter G. Suarez, MD, MPH
  • President and CEO
  • Institute for HIPAA/HIT Education and Research

2
NPI Risk Assessment and Contingency Planning
  • Definition of Terms
  • Risk Assessment evaluation of risks and
    vulnerabilities that could negatively impact the
    business and system operations in an
    organization, and the likelihood of occurrence.
  • Risk Management is the actual implementation of
    measures to sufficiently reduce an organizations
    risk of having its business and system operations
    compromised
  • Contingency Planning the alternative steps that
    an organization need to be ready to be put in
    place in order to ensure that the organization
    can continue doing business, when established
    routines are disrupted

3
NPI Risk Assessment and Contingency Planning
NPI Electronic Transaction Chain
4
NPI Risk Assessment and Contingency Planning
  • Identify and assess the NPI readiness of three
    critical dimensions of the NPI Electronic
    Transaction Chain
  • Providers (Individual and Organizational)
  • Originators of an Electronic Transaction
  • Receivers of Electronic Transactions

5
NPI Risk Assessment and Contingency Planning
  • NPI risks are real and easy to identify
  • Claims may be rejected, pended, payment
    continuity issues may occur
  • Need for manual/alternative verification, slow
    down in overall processing
  • Risks for payment misallocations also exist
    (wrong NPI of the wrong provider for the wrong
    set of services)
  • If non-compliance, risk of exposure to
    violations, sanctions
  • Quantifying these risks is much more difficult
  • For payers and clearinghouses What would be the
    net effect and cost of continuing to accept
    non-compliant claims vs. enforcing the
    requirements?
  • For providers What would be the net effect and
    cost of continuing to submit non-compliant claims
    vis-à-vis the cost of violating the rules and
    being exposed to claim rejections?

6
NPI Risk Factors
  • Enumeration Factors
  • Primary providers dont have their NPIs
  • Secondary providers dont have their NPIs
  • Subpart Factors
  • Providers choice of subpart enumeration does not
    match payers legacy identifier approach
  • Taxonomy code(s) self-identified and reported by
    provider does not match payers assigned
    specialty code
  • Dissemination Factors
  • Lack of access to NPPES data
  • Payers, clearinghouses and provider have not
    collected NPIs of providers they do business with
    and need

7
NPI Risk Factors
  • Transaction-specific Risk Factors 837s, 835s,
    Rx claims
  • Ability to appropriately identify billing and
    pay-to provider in claims
  • Use of correct taxonomy code to supplement
    billing provider information (One or more
    Taxonomy Codes allowed? Required? Which taxonomy
    code?)
  • Requirement of Zip4

8
NPI Risk Factors
  • Transaction-specific Risk Factors 837s, 835s,
    Rx claims (cont.)
  • Ability to report secondary provider IDs
  • Having access to referral, prescriber, ordering
    NPIs
  • Ability to report the appropriate NPI on an 835
    when Legacy sent on 837
  • Ability to do a hard-transition for pharmacy
    transactions that will not be able to handle dual
    identifiers
  • Other Transactions
  • Handling eligibility, enrollment, other
    transactions with and without NPIs

9
NPI Risk Factors
  • IT Infrastructure Factors
  • Major system changes, beyond NPI scope, underway
  • Readiness of internal NPI-capable software
  • Reliability and completeness of internal
    crosswalks
  • Personnel education
  • Environmental Factors
  • Steady outflow of rules and regulations, new
    laws, implementation of new paper forms competing
    for internal resources
  • Clean claim and prompt payment laws that affect
    the processing of claims
  • Health plan agreements with employers/public
    programs for minimum claim processing performance
    thresholds

10
NPI Contingencies - Providers
  • Plan for internal contingencies (how to handle
    delays, problems with new NPI-ready application,
    need to prepare for an important volume of
    manual/phone follow-ups, payment continuity
    issues)
  • Continued challenge to obtain and maintain
    secondary NPIs
  • Uncertainties about what each payer and
    clearinghouse will send back on 835s, and whether
    the right amount has been adjudicated to the
    right NPI/provider for the right service

11
NPI Contingencies - Providers
  • Uncertainties about how each payer and
    clearinghouse will operate immediately after the
    compliance date
  • Some might reject claims without primary provider
    NPI, some might continue to accept NPILegacy,
    some might even accept legacy only transactions
  • How will they handle secondary provider NPIs?
  • What about taxonomy codes and subpart mismatches?
  • Contingencies for small health plans!

12
NPI Contingencies - Payers
  • Handling a mismatch of incoming transactions
  • Some with NPIs only, some with NPILegacy, some
    with Legacy Only some without secondary provider
    NPIs some without the right taxonomy codes
  • Creating defined paths for specific situations
    (which to drop to manual, which can be passed
    and follow-up with provider afterwards)
  • Establishing crosswalk contingencies
    (back-up/manual processes to resolve matching
    problems)

13
NPI Contingencies - Payers
  • Implementing a payment continuity strategy
    (revenue cycle management, payment monitoring,
    error resolution plans) to ensure that issues
    with internal business processes, systems, or
    transaction processing will not adversely affect
    prompt payment requirements, contracted
    processing thresholds or the delivery of care to
    members
  • Establishing a strategy to handle transactions
    with atypical providers
  • Handling crossover/COB claims with other plans

14
NPI Contingencies - Clearinghouses
  • Hardest position
  • Significant variability on readiness among
    provider clients
  • Significant variability on readiness, coding
    requirements from payer clients
  • Risk to be seen or become the bottleneck
    between providers and payers, stopping
    transactions sent by providers that dont meet
    the vendor general requirements, yet some of the
    payers at the receiving end would take
  • Need to also create defined paths for specific
    situations (which transactions to allow to come
    through, which to stop)

15
NPI Contingencies - Clearinghouses
  • Alternative plans to handle the lack of time and
    data available for end-to-end testing (not just
    unit testing)
  • Also challenged with the need to develop
    crosswalk contingencies (back-up/manual processes
    to resolve matching problems)
  • Contingencies for small health plans!

16
Take Home Messages
  • NPI Transition will continue for quite some
    time beyond any deadline
  • Balance being compliant with doing the right
    thing
  • Be flexible and adaptable with your processing
    policies and transaction edits
  • Communicate periodically how things will be
    handled
  • Monitor and isolate outlier cases of lack of
    use/misuse of NPIs
  • Prepare for potential significant increases in
    manual follow-ups
  • Make a Good Faith Effort to be compliant
  • Treat your contingencies as an evolving process!

17
  • Thank You!
  • Walter G. Suarez, MD, MPH
  • President and CEO
  • Institute for HIPAA/HIT Education and Research
  • Alexandria, VA
  • Phone (952) 221-3841
  • Email walter.suarez_at_sga.us.com
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