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Statement To

The Workgroup for Electronic Data Interchange – WEDI

April 4, 2006
Presented By:
James D. Whicker
Chair-Elect of the Workgroup for Electronic Data Interchange (WEDI)

Mr. Chairman and members of the sub-committee, I am Jim Whicker, Chair-elect of the Workgroup for Electronic Data Interchange, or WEDI.  I am also Director of EDI for Intermountain Healthcare, and serve as EDI Liaison for AAHAM, an organization of provider patient financial services professionals.  I mention this in order to be clear as to the constituency I represent as a member of WEDI.  I would like to thank you for the opportunity to present testimony regarding the National Provider Identifier (NPI).  I would like to thank Dr. Walter Suarez and the members of the WEDI NPI Outreach Initiative (NPIOI) for bringing the bulk of this information together for today’s discussion.   As time is limited, I will only be able to discuss summary topics.  WEDI welcomes the opportunity to provide additional detail and recommended solutions to concerns raised here.

The concept of a standard provider ID to replace the identifiers needed for millions of individual providers with thousands of payers has some obvious benefits, not only for simplifying the identification of a provider to a payer, but also for many secondary reasons.   WEDI’s concerns lie in the issues surrounding the implementation of NPI, not in the usage of the number for its intended purposes in Administrative Simplification.


As with all other aspects of HIPAA, education and outreach will play a critical role in the successful planning, transition, implementation, and full adoption of the new National Provider Identifier.   To that end, WEDI is actively involved in addressing this issue.

WEDI is also conducting an NPI Hearing on April 18th, 2006in Chicago.  As of the end of March, we have registered over 110 attendees, with 22 individuals or organizations planning to provide verbal and written testimony, with a few additional planning to provide written testimony only.  The hearing panel will evaluate the information provided and will develop additional recommendations that WEDI receives from this process.

Recent experiences with the implementation of the HIPAA Transactions and Code Sets, Privacy and Security regulations have shown the significant challenges that the health care industry faces without a coordinated communication and outreach strategy. A national coordinated strategy will help ensure early awareness across all covered and affected organizations, provide a consistent level of understanding regarding the regulations, and offer the opportunity to share planning, transition and implementation experiences, approaches and timelines.

On September 30, 2004, WEDI sent the Secretary of Health and Human Services an advisory letter on concerns and issues regarding the NPI. The letter summarized the results of the June 2004 Policy Advisory Group (PAG) forum on the NPI.  The WEDI letter elaborates on the need for education and outreach.  Other groups have emphasized the need for education and outreach.

WEDI has implemented the NPI Outreach Initiative, or NPIOI, to serve as the focal point to the industry for information related to the planning, transition and implementation of the NPI. The primary role of the Initiative is to 1) develop and implement a national coordinated NPI outreach plan; 2) act as a central repository for NPI resources, and 3) disseminate industry consensus information on policy and operational issues regarding the deployment and use of the NPI. The outreach plan will be targeted to providers, payers, clearinghouses, vendors, and other industry participants affected by the new NPI.

The focus of the NPIOI is to ensure early awareness across all covered entities and affected organizations, provide a consistent level of understanding regarding the regulations, and promoting the sharing of information regarding NPI planning, transition and implementation experiences, approaches and timelines.

In March, WEDI NPIOI hosted an audio cast aimed at small providers that drew an audience of over 250.  We will present an encore again on April 27, with more planned targeting other audiences in the future that will include audio casts, regional NPI programs, and an industry forum in August.  WEDI NPIOI has created an “NPI Resource Center” on the WEDI Website ( where the industry will find a number of helpful documents that cover everything from basic overviews to CMS FAQs to WEDI SNIP NPI white papers.  In particular, the “Dual Use” NPI white paper has been very well received by the industry as a resource for implementation.

This initiative, alone, cannot resolve all the issues surrounding implementation of the NPI.  We’ll discuss some of those key issues now.

Enumeration Process

The current application process on an individual provider basis (Type 1 NPIs) seems to be working well.  Providers are having great success using the web application, as well as the manual paper process.

However, delays in the implementation of the bulk enumeration (EFI) have put significant risk to the successful transition and adoption of the NPI by May 23, 2007, less than 400 days away.   As of today, only 400,000 providers have been enumerated, around 15% of the total expected number.  Many larger organizations have waited to begin the enumeration until the bulk enumeration was finalized.

Only until last week, the EFI Certification Statement, the legal document that an organization is required to sign in order to become an EFI Organization (EFIO) and apply on behalf of its providers, became available.  But as of today, the actual EFI process, this is, the process for an organization to officially become and EFIO and for CMS to begin accepting EFI submissions has not yet been started.

As a result, many large organizations with large numbers of individual providers and provider organization components to be enumerated have resorted to a one-by-one manual data-entry process or paper process.  This is causing significant delay in the start of their implementation, testing, and communication of NPIs, as well as adding workload for the NPPES, and it is requiring the manual keying of data for both the provider and NPPES, increasing the chance for introducing errors into the system.

Atypical Service Providers, those that are generally non-health care providers as defined by HIPAA, are of additional concern. CMS should be more active in helping the industry define who these providers are and who they are not.  The industry will be facing a significant challenge in trying to identify national approaches to enumerating these providers, given that the NPPES system will not be available for them.  Regional approaches are being considered, but we strongly believe a national approach will be ultimately needed and simplify the process.

The NPPES system is taken off line on occasion for system maintenance. Most information systems have a planned downtime for maintenance, or at a minimum, will give users advance notice whenever possible. We understand that the NPPES Contractor does not do this, and the system is taken out of service at a minimum once every three months, but no advance notice is given to users. In addition, planned downtimes occur during regular work hours, not during off hours or on weekends to lessen impacts to users. Due to the importance of this systems’ availability to the enrollment process now, and to future inquiry capability, this issue needs to be addressed. WEDI recommends advance notice to users whenever possible regarding downtime on the NPPES system and that planned downtimes occur before and after normal work hours during weekdays or on weekends whenever possible.

Enumeration of Organization (Type 2) Subparts

There continues to be significant confusion and lack of definition on how providers are to determine which components or subparts they need to enumerate.  The industry is at a stand-still on this issue, with providers waiting for commercial payers and Medicaid programs to state their subpart enumeration expectations, commercial payers and Medicaid programs waiting for each other to describe their expectations, and all expecting further clarifications on the “Medicare Subpart Enumeration Expectations” policy document recently released by CMS.  While the rule states that payers cannot dictate how a provider self identifies, most providers are reluctant to move without a clear understanding of what payers DO expect.  If not done correctly, the provider risks not being paid or not being paid accurately.

The release of this policy document by Medicare was an important step in helping to clarify the subpart issue.  But a number of questions remain.  One of the original questions related to this issue focused on the identification of specific federal program regulations that require the enumeration of specific provider components.  Providers enrolled in the Medicare program, and their subparts, are encouraged to enumerate themselves with NPIs in a way that mirror the Medicare Program provider enrollment today.  Thus, the document promotes the notion that if an entity has parts that are separately enrolled with Medicare or are separately surveyed by Medicare with their own Medicare Billing Number; the organization is encouraged to obtain an NPI for each of those parts.

The paper also states that if an organization provider has identified a subpart and decided to obtain an NPI for it, and the subpart is not enrolled as a Medicare provider, if the entity uses that subpart’s NPI in a transaction with Medicare, the transaction will not be able to be processed unless that NPI is made ‘known’ to Medicare.  The process for being made ‘known’ is still in question, and the effect of this further detailed identification and the payment process under Medicare is unknown.

Other payers might define their subpart enumeration expectations to providers in a similar manner, thus putting providers at a quandary, having to make enumeration decisions that will affect the way they do business with payers, that may result in delays or rejections in the processing of transactions.  This type of question leads one to believe that type 2 providers will have multiple NPIs and will need to decide which NPI to use depending on the payer being billed.  This defeats the purpose of administrative simplification, making the usage payer specific.

WEDI’s earlier recommendation was that, based on federal program requirements and private sector contractual obligation – providers choose the level of NPI granularity that best meets their needs and use their chosen level of granularity in transactions with all health plans.  That recommendation is proving difficult to apply, given the language in the Medicare transmittal about NPIs needing to be “known” to Medicare, which implies Medicare will only recognize Medicare-determined levels of granularity, both in processing its claims and in passing NPIs for crossover/coordination of benefits.

We are also concerned that the decisions regarding subparts are not considering the potential future impact of the next version of standard transactions.  Version 5010 will require providers to use the lowest level of granularity across all payers, which will put providers at risk of having to send a transaction with an NPI that a payer does not recognize.

It is expected that these issues will be raised during the WEDI hearing later this month and recommendations may be forthcoming from WEDI afterwards.

Use of NPIs in HIPAA Transactions

There exist questions and confusion on behalf of both payers and providers on how organizational NPIs are reported in Coordination of Benefit scenarios.  Without additional direction, there is a probability that providers will be using different NPIs for different payer situations, concerns center on how these NPIs can be matched by payers in cross-walks and whether that will cause delays or errors in processing, or cause the wrong fee schedule to be applied – resulting in incorrect reimbursements to the provider.   Applying payer-specific NPI usage complicates any ability to compare data payer to payer, provider to provider, as well as complicates the process for payer to payer COB (i.e. Medicare crossover transactions).


Regarding paper transactions, there are concerns about the ability to meet timelines for converting to the paper forms modified by the NUBC and NUCC, in light of competing priorities with the changes needed for NPI in the electronic transactions, as well as other system changes needed.


We are also concerned that a provider may be negatively impacted (i.e., not paid) due to requirements they must include on their claim the NPI of a non-related third party — the ordering or referring provider.  If the ordering or referring provider is required to have an NPI and delays in obtain it, refuses to disclose it, or the rendering provider does not have access to a data source to obtain it, the claim may not be processable.  WEDI recommends that the NPPES be searchable, and available to the industry in a timely manner in order to develop access capabilities to the data.

NPI Dissemination

In order to process a transaction that contains NPIs, it necessary that all involved trading partners have access to the NPI information.  The dissemination process is going to be one of the most critical steps in the successful adoption and implementation of the NPI.  WEDI believes that to be successful, implementation of the NPI means:

  • Patient access to health care will not be negatively impacted by NPI processes.
  • Quality of care to the patient will not be adversely affected.
  • Overall health care costs will be reduced.
  • Timely payment to providers for health care services rendered will be assured.
  • Potential for fraud and abuse will be controlled.
  • Public Health data processes, the adoption of Health Information Technology (HIT), Electronic Health Records (EHR), and Regional and National Health Information Exchanges will be enhanced
  • Critical health care operations such as outcomes measurement and reporting, peer review processes, bioterrorism prevention, planning for new services and public health needs will not be compromised.

There needs to be a distinction of the two processes related to NPI Dissemination, each with its own set of challenges and issues:

First, access to NPPES Data (NPI Dissemination per-se) – the ability for certain organizations to request NPI-related information from the NPPES database.

Second, the sharing of NPI Data between trading partners and others (NPI Information Exchange) – the ability of health care organizations (covered entities, non-covered health care providers and others) and their trading partners to exchange NPI-related information about providers

We hope that the NPI Dissemination from NPPES turns out to be the most efficient and cost-effective method for payers and providers to populate their provider identifier databases and crosswalks.  Providers and payers need to have the ability to validate the accuracy of the NPIs provided from an outside entity

By obtaining the NPI information directly from NPPES, payers and providers will be able to 1) go to one place for the information and 2) obtain the information directly from the primary source, for purposes of verification of NPI accuracy.  This will avoid payers and providers having to go to each other to obtain their compartmentalized NPI information.  For example, a Medicaid Program or a Blue Cross/Blue Shield plan with 80,000 health care providers in their network (many large health plans around the country have these size of networks) will need to obtain NPIs from all or most of those health care providers.  Going directly to NPPES for this information will avoid having the health plan go to each of its providers to collect the NPI information.

The value of the NPI information exchange from the NPPES is significant.  WEDI is concerned that due to the long delays in the publication of the NPI Dissemination Notice and the start of NPI Dissemination from NPPES, providers and payers are already developing proprietary methods of communicating NPI information for crosswalks.

Phone calls, faxes, letters, emails, spreadsheets, etc. are all being used, each entity having their own format/process.  What should be a standard process is evolving again into a quagmire of proprietary processes – similar to what happened with implementation guides and the subsequent ‘companion guides’ for the HIPAA transactions.  This results in inefficiencies and a waste of resources and valuable time for those implementing.

WEDI is planning to address this issue through our WEDI SNIP NPI Workgroup, developing a recommended standard mechanism to be used by the industry to exchange NPI information.  WEDI would welcome endorsement for that process.

Delays in the release of the NPI Dissemination Notice and the start of NPI Dissemination by NPPES have already put the industry at high risk of not achieving compliance by the May 2007 NPI compliance deadline.  And any further delays on these two steps (publication of notice and start of NPI Dissemination from NPPES) will significantly increase this risk, as health care organizations will not be able to develop and put in place plans for NPI Dissemination and NPI Information Exchange in time to meet the already very tight project plan deadlines that many of them already have establish for this.

One of the biggest challenges ahead for the health care industry is that NPPES will not be accessible via an interactive, look-up method for requesting and obtaining the NPI of a provider.  Today, hundreds of thousands of providers depend on their ability to obtain the UPIN number of a provider via simple online, free interactive databases.  Many situations exemplify this need, including (but not limited to) Referring provider ID; Ordering Provider ID; Hospital Billing for Physicians with Admitting Privileges; Services Provided by Providers in Skilled Nursing Facilities (SNFs); and Pharmacy Needing Prescribing Provider’s NPI.  WEDI is concerned that the NPI Dissemination Notice from CMS will be too restrictive on the ability of the organization receiving the NPI information from NPPES to use (internally) and disclose to outside trading partners, the NPI information.

We are concerned that the NPI Dissemination Notice will restrict access to NPPES data to only a narrow group of entities, excluding others who might have legitimate business needs to obtain NPI information.  WEDI strongly recommends that the industry should have the ability to use and disclose NPIs from providers outside of their organization with other trading partners when the purpose is for treatment, payment and health care operations, regardless of the source of the NPI information and without restrictions.

We are concerned that the data elements that will be available to be requested from NPPES will not include what the industry considers to be essential elements.  The most critical data element contained in the NPPES system, is the NPI number itself.  However, other data elements maintained in the NPPES system will be essential to be able to appropriately establish correct identities and tie an NPI to the appropriate provider (via a cross-walk) in the entities system.

We are concerned that the NPI Dissemination Notice will go too far into regulating and impacting the ability of trading partners within the industry to exchange NPI information. We recognize that entities will have many sources from which they will receive NPI information.  The only two primary sources will be NPPES and the provider to whom an NPI has been assigned.  There will be many secondary sources of NPI information.  We are very concerned that the NPI Dissemination Notice will impose restrictions on the use and disclosure of NPI information depending on the source.

NPI Industry Awareness, Education and Outreach

The key message over the coming months, should there not be a delay in implementation dates, must be communication.  Communicate with your payers, communicate with your providers, communicate with your clearinghouses, etc.

WEDI has embarked on an aggressive process of educating the industry and developing tools and information to streamline and standardize the process via information on our website, educational seminars, Webinars, conference calls, white papers, and the National Provider Identifier Outreach Initiative (NPIOI).  This outreach and education is essential, and support and partnership from CMS and other involved government entities would help bolster our efforts.

We are concerned that there continue to be clear pockets of industry groups that have not yet heard about the NPI or are not receiving the information they need.  Or, they are not receiving it in a format that helps them to be effective in implementation.  Assistance in reaching these groups would be appreciated.

WEDI is a voluntary, non-profit organization and we recognize that the size and scope of the industry awareness, outreach and education challenge that the industry faces today is much larger than what can be delivered through voluntary efforts without assistance.  An expanded role for CMS, as was done for Transactions, Privacy and Security would be beneficial.  A focused campaign directed to providers to obtain and implement the NPI is needed.

We suggest establishment of a mechanism to collect, evaluate, and address the many questions coming from providers, payers and the industry at large.  This will be complementary to, and NOT duplicative of the 21 NPI FAQs published thus far by CMS on their website.

We suggest that more state and regional NPI efforts should be promoted that bring to the table local payers, providers and clearinghouses to address readiness, outreach, transition plans, and implementation.

As stated before, we are also concerned that the decisions regarding subparts are not considering the potential future impact of the next version of standards.  Version 005010, building upon the real-world impacts of the NPI Final Rule, CMS FAQ 5816, and correlations between the electronic 004010A1 and paper claim forms, will require providers to use the lowest level of granularity across all payers.  This will put providers at risk of having to send a transaction with an NPI that a payer does not recognize.

The support of CMS, NCVHS, and HHS in removing the obstacles surrounding the implementation of the NPI will help the industry achieve the results intended by the current deadline.  WEDI looks forward to continue working with CMS, NCVHS, and HHS to improve rollout of the NPI within the Healthcare Administrative Simplification transactions.

Mr. Chairman and members of the sub-committee, thank you for the opportunity to testify. This concludes our statement.