[This Transcript is Unedited]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
NATIONAL COMMITTEE ON VITAL AND HEALTH STATISTICS
SUBCOMMITTEE ON STANDARDS AND SECURITY
January 24, 2007
National Center for Health Statistics
3311 Toledo Road
CASET Associates, Ltd.
10201 Lee Highway, Suite 180
Fairfax, Virginia 22030
List of Participants:
- Harry Reynolds, Co-Chairman
- Jeffrey S. Blair, MBA, Co-Chairman
- Denise Buenning, MSM
- Simon Cohn, M.D.
- Judith Warren, Ph.D
- Marjorie Greenberg
- Michael Fitzmaurice, Ph.D
- Vivian Auld
- Nancy Spector
- Karen Trudel
- Justine Carr, M.D.
- Steve Steindel, Ph.D
TABLE OF CONTENTS
- Introduction and Opening Remarks
- Panel I – NPI Provider
- Carole J. Magoffin
- Karen Raines
- Larrie Dawkins
- Frank Kyle, Jr.
- Mari Rose Johnson
- Panel II – Vendors/Clearinghouses
- Mitchell Icenhower
- Catherine Schulten
- Stacy Trease
- Robert Burleigh
- Panel III – Pharmacy
- Michele Vilaret
- Kathryn F. Kuhn
- Annette Gabel
- John Lavin
- Panel IV – Plan/Payor
- Marilyn R. Zigmund Luke
- Justine Handelman
- Cathy Carter
- Proposal Presentation: Patrice Kuppe
- Subcommittee Discussion
P R O C E E D I N G S (9:05 a.m.)
MR. REYNOLDS: We will go ahead and get started. This is the
meeting of the Subcommittee on Standards and Security, a subcommittee of NCVHS.
NCVHS is the statutory advisory body to the Secretary of Health and Human
Services. My name is Harry Reynolds. I am from Blue Cross Blue Shield of North
Carolina. I am the co-chair along with Jeff Blair.
In a moment we will go through and have everybody introduce themselves. I
would ask members of the committee to, as you introduce yourself, let us know
whether or not you have any conflicts of interest based on the hearings that
are going on.
This is a very tight agenda. I ask you to be crisp, all of us to be crisp.
This thing could stack up like the Atlanta airport on a Friday afternoon if we
are not real careful. Some of you may get to testify on Saturday morning if we
are not careful. So it is very important that everybody stays on message and on
track, and we are going to give you some messages that we would like to have
you focus on.
I would ask everybody to turn your cell phones off. We are being recorded,
and we are on the Internet, to make sure everybody is aware of that.
So with that, I would like to go around the room and start the
introductions. Jeff, we will start with you, please.
MR. BLAIR: I am Jeff Blair, Director of Medical Informatics for Loveless
Clinic Foundation. To the best of my knowledge I have no conflicts of interest
with the topics that we will be receiving testimony on today.
DR. CARR: Justine Carr, Beth Israel Deaconess Medical Center, no conflicts.
MS. TRUDEL: Karen Trudel, Centers for Medicare and Medicaid Services,
liaison to the full committee, staff to the subcommittee.
MS. JOHNSON: Mari Johnson, American Medical Association.
MR. KYLE: Frank Kyle, American Dental Association.
MR. DAWKINS: Larrie Dawkins, Medical Group Management Association.
MS. RAINES: Karen Raines with HCA, representing the Federation of American
MS. MAGOFFIN: Carole Magoffin, representing the National Minority Quality
DR. FITZMAURICE: Michael Fitzmaurice, Agency for Health Care Research and
Quality, liaison to the full committee, staff to the Subcommittee on Standards
DR. WARREN: Judy Warren, University of Kansas School of Nursing, member of
the subcommittee, and I am not aware of any conflicts I have today.
DR. COHN: Simon Cohn, Kaiser Permanente, chair of the full committee,
member of the subcommittee, and no conflicts of interest.
MS. BUENNING: Denise Buenning, Centers for Medicare and Medicaid Services,
Office of E-Health Standards and Services and lead staff to the subcommittee.
MS. SCHULTEN: Catherine Schulten, EDIfecs.
MS. VILARET: Michele Vilaret, NACDS.
DR. FRIEDMAN: Maria Friedman, RxHub.
MR. MOLANDER: Chris Molander, CMS, Office of E-Health Services.
MS. HOLLAND: Elizabeth Holland, CMS.
MR. TRENKEL: Tony Trenkel, CMS.
MS. WEIKER: Margaret Weiker, EDS.
MR. LAVIN: John Lavin, Caremark.
MS. GABEL: Annette Gabel, MEDCO.
MR. ICENHOWER: Mitch Icenhower, Siemens HDX.
MS. TIPPE: Therese Tippe representing WEDI.
MS. GOLDSTEIN: Lisa Goldstein, Medical Group Management Association.
MR. KALISH: Richard Kalish with CAQH.
MR. OFANO: Bill Ofano with Blue Cross Blue Shield Association.
MR. ANDERSON: Anderson, NCHICA.
MS. GILBERTSON: Lynn Gilbertson, National Council of Prescription Drug
MS. KUHN: Katherine Kuhn, National Community Pharmacists Association.
MR. REYNOLDS: As a matter of order, each of you as you are speaking — and
you did a good job in your introductions — make sure you turn your microphone
off, because the way this is set up, if there is more than one microphone on at
a time we do get feedback. So that would be good.
Our subject the first part of today is the national provider ID. To put
everybody in context, we sent a letter to the Secretary on November 29, and I
will just read one paragraph.
“The committee has heard testimony on several occasions regarding the
readiness of providers, plans, clearinghouses and the software vendors that
support them to use the NPI in HIPAA transactions. We have concluded that while
significant progress is being made toward compliance, some key activities may
not be completed by the compliance date, which has the potential to delay or
disrupt payments to providers.” That was one of our comments. Then in the
end, we told the Secretary that we would hold this subsequent hearing to get a
full update. So we are well aware of the subject, well aware of the subject, we
have heard it over and over again.
What we would like to do today as far as going through this is — then the
other thing, giving you the picture of the whole hearing and why some of your
comments today will be very helpful to us, the first part of the hearing is
NPI. The second part of the hearing is expediting standards. So on the one
hand, we will be talking about something that is not going as well as it could
be, and then we are going to be talking about speeding things up. So in the
end, we need to be able to think this whole process through so that those two
work out, if they are going to. So that is key.
We have four focus questions. There is a lot of testimony, and if everybody
reads everything they have in their testimony it is going to be a long time. We
have four key questions. Will you be ready on May 23; if no, what are the
reasons; what can we do between now and May 23 to get the industry ready, and
if you think May 23 can’t be met, then if you have some other idea, why would
anybody be ready then. So those are the kind of things that we have to try to
adjudicate as we recommend whatever we recommend out of this hearing to the
Secretary as to how we go forward to do this. So that is what we want to focus
on, because we owe the Secretary some type of a letter, unless everybody says
we are going to be done by May 23. Then we will congratulate everybody and move
on. If not, then we are going to try to come up with some kind of a
recommendation that has some kind of a process that would allow this thing to
occur in some kind of orderly way for the whole industry.
So with that, I am just going to go right down the order on the agenda.
Carole, you can please start.
Agenda Item: Panel I – NPI Provider
MS. MAGOFFIN: Thank you very much for the opportunity to be here on behalf
of the National Minority Quality Forum. I apologize that the CEO, Gary
Puckerin, is not here so that we would have a diversity represented in our
organization that we represent, but I guess there will be some modicum of
The National Minority Quality Forum is also evolving from a ten-year-old
organization called the National Minority Health Foundation Organization. So we
are in transition.
I apologize also that we are very new to this issue. I have been in quality
of care for 20 years, dating back to Mike Fitzmaurice. I am happy to see him
here today, because it seems to be a different crowd of folks. This group seems
like the same group of quality folks that all know each other and we are new to
this issue, so we are just getting up to speed. I think our comments will be at
about the 100,000 foot level.
We are very much aware of the move to standards and have followed with
interest the importance of assigning NPI. But obviously we are not doing the
heavy lifting that so many are doing. But we do think perhaps in this
implementation phase there are some issues that could be addressed in getting
better participation by minority providers. So congratulations to all of those
who are doing the heavy lifting.
I also apologize, I will probably read most of the comments, and you can
stop me if we go over ten minutes.
As I said, I am Carole Magoffin. I am Vice President for Quality with the
National Minority Quality Forum. I am representing the CEO and President, Gary
Puckerin. NMQF is a nonprofit minority-led organization dedicated to insuring
the delivery of high quality health care services to high risk racial and
ethnic populations and communities.
NMQF, the formerly National Minority Health Foundation, assists and
collaborates with the private sector, government leaders, providers and other
health professionals, physicians, consumers, administrators, community and
faith based organizations, policy makers at all levels. Aims are accomplished
by conducting research and analysis of existing evidence, guidelines and
measures used to inform the organization of health and medical care delivery
systems and the management of resources used to address minority health
concerns in America.
Physicians and health disparity leaders of position serve on the NMQF
Scientific Advisory Board and its executive committee. NMQF was founded in 1998
by Dr. Gary Puckerin to strengthen national and local efforts to eliminate the
disproportionate burden of premature death and preventable illness in racial
and ethnic minorities and other populations through the use of evidence based
data driven initiatives.
The National Minority Health Month, which is in April every year, was
launched in 2001 in response to Healthy People 2000 in collaboration with
then-Surgeon General David Satcher. Since 2003, NMQF has conducted an annual
health disparities summit and awards dinner during the month of April that has
focused on data driven solutions to improving the quality of health services to
high risk racial and ethnic populations and communities.
NMQF has also developed a comprehensive relational data platform for
identifying the prevalence of health status and health care disparities at the
zip code level, allowing NMQF to house vital statistics, demographic,
environmental, claims, prescription drugs, clinical laboratory values, health
care access points and other data elements in one centralized data warehouse.
The resulting disparity atlases for chronic conditions and diseases allows NMQF
to measure and forecast health status in small geographic areas, evaluate the
impact of specific interventions, monitor changes in health outcomes, and to
serve as a valuable resource for the broad range of ethnic and racial
NMQF supports implementation of a standardized national patient identifier
number system in a phased and focused manner, but not on May 23, 2007. Data
from such a system will ultimately improve clinical data for both patients and
providers and greatly enhance the ability of clinicians, health systems and
researchers to adjust the widening health status and outcome disparities for
ethnic and racial minority populations.
Supporting the national provider identification number is however like
supporting the need for mothers and apple pie. NMQF is not aware of any special
outreach to minority physicians that might have yielded an increase in
applications by minority providers for provider numbers. Implementation of
standardized NPINs will however not solve the problem of tracking populations
treated in free or charity supported clinics in urban and rural areas serving
minority populations. These providers often do not bill for services.
Given the vast majority of providers that have not applied for an NPIN, and
given the likelihood that a large number if not a majority of these providers
without NPINs may be treating ethnic and racial minorities, a May 23
implementation date is unfathomable. Furthermore, problematic or failed
implementation will likely do irreparable harm to the broad support that
currently exists for implementation of electronic health records and personal
health records within the overall e-health agenda.
EHRs and PHRs are needed for critical national surveillance and reporting
programs addressing quality of care issues. Some of the issues we have
identified that are obvious: NPIN enrollment is not high on the radar of
minority medical and health organizations; enrollment and implementation
language, terms and acronyms are very offputting if not unintelligible to
physicians, providers and non-IT experts and professionals; there are not
sufficient programs in place to identify providers and to focus outreach
efforts for community providers treating ethnic and racial minority
populations; needed outreach to free clinics or community health centers,
rural, urban and other, does not seem to be appreciated or recognized.
CMS’ Peter Bautch reported recently that 20 percent of physicians in some
geographic areas are treating 70 percent of the population, which speaks to the
need to prioritize provider enrolment in health disparity zones. Efforts to
date do not appear to reflect partnerships with minority medical institutions
or minority health organizations, a move that would be crucial in motivating
providers and physicians who treat special populations to apply for NPIN
The government cannot risk a flawed NPIN response system, as would be the
case with a May implementation date, resulting in flawed quality and data and
disparity reporting at all levels. Enrolment of sufficient numbers of
physicians and providers treating minority populations is critical if the new
program is to have credibility among minority providers providing the care to
ethnic and racial minorities.
A caution also is that minorities are tomorrow’s majority of aging
Americans. On January 12, 2007, HHS released its annual national health
disparities report for 2006. It indicated that according to recent data, there
is a continuing disturbing downward trend in quality of care for minorities,
although the aggregate numbers for the overall population are up two to three
The reports states that blacks receive poorer quality of care than whites
for 73 percent of the core quality measures, up from 43 percent in 2005.
Further, Hispanics receive poorer quality of care than non-Hispanic whites for
77 percent of the measures, up from 59 percent in 2005, demonstrating a
seriously widening gap for the third straight year. Quality of care stories for
other minorities such as Native American Indians, Pacific Islander Americans,
Asian Americans, are also of great concern.
In addition, the jury is still out on whether current clinical evidence and
guideline protocols actually represent best practice for improving health and
medical care for certain ethnic and racial minorities. Most treatments, drugs
and therapeutics are not tested in clinical trials that are powered adequately
to determine effects, positive or negative, on minority populations. Many
quality measures lack specificity regarding significant differences in
responses by minorities to treatments that are masked in aggregate storing of
Lacking standardized reporting nomenclature and numbers applied uniformly
by all providers, we will be contributing to widening the gap in health
quality, leaving no means of system surveillance of risk for these vulnerable
We have a few brief recommendations. We feel implementation should be in
phases, targeting known geographic disparity areas or zones with special
attention to provider specialty, in order that outreach methods appropriately
reflect the cultural mosaic of target communities and accurately identify
specific problems and issues preventing providers from applying for NHINs. A
one size solution isn’t fitting all.
Congressional action should be considered if necessary in order to
forestall implementation of a failed or at best flawed and error-ridden NPIN
implementation process which could lead to significant setbacks. There are no
drivers with regard to implementing the new NPIN system.
Target regions or communities should be established for NPIN registration
as part of a phased in approach focusing on health disparity zones, in order to
account for minority groups at risk.
Regional and community outreach should enlist the input of
Hispanic-American, African-American, Asian-American, Native American, Asian
Pacific Islanders and others to insure outreach efforts connect with and
account for providers treating ethnic and racial minority populations.
Lastly, we recommend that CMS and NCHS or HHS consider investing resources
in the collaboration that have the potential to effectively identify health
disparity zone providers treating American ethnic and racial minority
We look forward to working with all parties as NPIN implementation moves
forward, in the hopes that there will be time to step back, reassess and
enhance the NPIN implementation plan.
MR. REYNOLDS: Thank you. We are going to listen to the whole panel, and
then we will have questions.
Karen, you would be next, please.
MS. RAINES: Thank you. Mr. Chairman and members of the Subcommittee on
Standards and Security, my name is Karen Raines. I am an assistant vice
president of regulatory compliance support for HCA. I am providing testimony
today on behalf of the Federation of American Hospitals.
The Federation is a national representative of privately owned and managed
community hospitals and health systems throughout the United States. We
appreciate the opportunity to provide testimony today on the NPI. Also of note,
I am a member of the National Uniform Billing Committee, also representing the
Federation, and was asked to let you know that I will be providing a copy of my
testimony following the meeting.
At HCA, our focus and attention to the NPI began in the first quarter of
2004, immediately following the January 23 release from HHS of the NPI final
rule. We immediately developed a project team and an infrastructure at our
corporate office to insure consistency with the way in which our hospitals,
freestanding ambulatory surgery, imaging and radiation oncology centers and our
physician practices would be enumerated, how we would address training and
education, system remediation and the other aspects involved in implementing
and operationalizing the NPI.
We developed extensive tool kits and other aids for our providers and an
extensive series of ongoing written communications and updates to keep them
abreast of our activities internal to the company and those within the industry
at large. We are in the process of completing extensive internal system
remediation to accommodate the NPI, and are working very, very closely with our
external billing vendors and clearinghouses to insure a timely and compliance
While HCA currently owns approximately 180 hospitals, we have to date
applied for approximately 700 hospital NPIs. While we understand the intent of
the NPI final rule and the value of a hospital having a single NPI, due to the
complexities associated with distinct part units and specialty units and the
uncertainty communicated to us by health plans as to what their expectations or
requirements would be regarding the NPI, for the most part we enumerated our
hospitals based on how their legacy provider numbers are currently assigned.
Relative to enumeration, our focus was on proactively eliminating as much
risk as possible and insuring that we would not only be paid timely, but that
the payment would be accurate based on the correct payment rates of payment
methodology used by the payor for the special type of clinical service provided
to our patients.
For example, in addition to providing acute inpatient hospital services,
many of our hospitals have psych, rehab, skilled nursing or swing bed specialty
units or subparts. From the payor’s perspective, there is a variety of
different payment methodologies that are used by the payor to accurately
process and adjudicate various types of claims. By billing all of the services
under the same global NPI, we were not able to obtain the information needed
from the payors to insure the receipt of a prompt and correct payment,
particularly since we were not successful in getting payors to confirm that
they would be willing to look at over data elements on the claim to determine
how to properly adduced that claim.
By approaching enumeration from this perspective, we collapsed
approximately 2,000 hospital legacy provider numbers into the approximate 700
NPIs. While we are clearly not at one NPI per hospital, we have significantly
reduced the number of legacy provider numbers we currently are required to
We found Fox systems, the NPI enumerator, extremely helpful and responsive
in meeting our needs. For example, many of our hospitals today have in excess
of 20 specific payor specific provider numbers. While the electronic NPI
application process limits the hospital to providing only up to 20 legacy
numbers, we successfully implemented a process with Fox that allowed us to
still provide them with the additional overflow numbers if you will that gave
us a greater sense of confidence that those additional legacy provider numbers
would be housed within the national plan and provider enumeration system or
We are currently now in the process of notifying all of our third party
payors, both federally and non-federally funded, of the NPIs that we have
obtained, and to discuss how we can collaborate together to insure that
thorough testing of both the claim and remittance advice occurs.
While we had limited success to date in finding health plans that would be
willing to test, we believe that successful testing of the electronic
transactions containing the NPIs is critical to a successful implementation.
Relative to the NPI confirmations obtained from the enumerator, many of our
third party payors are requesting hard copies of the NPI acknowledgements we
have received. So there has been an additional need for providers to develop
and implement a process to support each of the unique requests received from
We have experienced many variances with the way in which detailed plans are
approaching the NPI and the requirements they are placing on providers. Some
payors are allowing the NPIs to be reported in bulk on electronic spreadsheets,
some are requiring hard copies of the confirmations to be mailed or faxed, some
want them registered on their own internal websites, and even though we are a
short number of months away from the May 2007 compliance dates, some payors are
still not able to provide any direction to hospitals as to what their
expectations, recommendations or requirements will be.
The most conservative approach and the one we believe does the most to
mitigate potential risk is to provide each payor with all NPIs and to follow up
with a copy of the confirmation from the NPPES if requested. Which brings me to
an area of vital concern that I would like to discuss, NPI dissemination.
While we understand that the NPI dissemination notice is in internal final
clearance with MCMAS, we believe that the time line associated with the release
of the notice or the policy is critical to the successful implementation of the
NPI. Again, from an HCA perspective, we have been informed by some private
payors that they are basing how they will implement the NPI on the sole
assumption that they will have access to NPPES and that this access will allow
them to successfully map or crosswalk the NPI contained within the electronic
transactions back to the legacy or unique payor specific provider number which
they currently have issued.
From a hospital’s perspective, since we not only have to report the
facility NPI on the claim but the NPI for each of the attendings, surgical,
rendering or referring physician, it is critical that we also be granted access
to the NPI so that we can obtain these physician NPIs, in a similar way to the
manner with which we retrieve physician UPINs today, to allow us to submit a
compliance and timely hospital claim form.
We are currently in the process of individually contacting over 400,000
physicians which have admitting, surgical or other privileges within our
hospitals, but we are also concerned with physicians which we don’t otherwise
have a relationship with, but who also refer patients to our hospitals for
outpatient services and how we will be able to successfully obtain the NPIs.
Without access to NPPES, providers should potentially expect to incur a
delay in claims submission and cash flow while they sought to manually obtain
these NPIs from their offices. Given that we are now into 2007, industry access
to the data in the NPPES system is one of the most critical aspects needed to
successfully achieve NPI compliance, both from a May 2007 implementation date
as well as being a critical component from an ongoing support perspective.
Again, I would like to thank you on behalf of the Federation of American
Hospitals for the opportunity to provide this testimony, and will be glad to
respond to any questions or points of clarification that you may have.
MR. REYNOLDS: Thank you, Karen. Larrie.
MR. DAWKINS: Good morning, and thank you. I am Larrie Dawkins. I am the
Chief Compliance Officer of the Wake Forrest University Health Sciences in Wake
Forest University in Winston-Salem, North Carolina. I spent about 35 years in
MGMA was founded in 1926. We have 21,000 members representing 12,500
organizations, and approximately 270,000 physicians. Our core purpose is to
improve the effectiveness of medical group practice in the knowledge and skills
of the individuals who manage and lead them. MGMA’s headquarters is in
In my testimony today, I would like to focus the attention of what MGMA has
learned from its members, the outreach that we have provided to practice
administrators, key issues and finally, offer a series of recommendations.
Our MGMA experience has been that we have not done a detailed survey, but
we have done informal polls with our members, and we shared these with CMS in
2006. In our queries with our members during face to face meetings and e-mail
questionnaires, we found that the majority of our members have their NPIs, not
as many have their type two NPIs, and fewer have identified whether they needed
subparts or not.
The readiness of practices to start generating NPIs on claims is a concern
for MGMA members. Although some practices have reported that their practice
management systems, which all of us use, were updated and capable of generating
NPIs and the proprietary identification number, many others have yet to have
their systems modified. In certain cases, the vendors have promised upgrades in
early 2007, while others provided no exact date. Costs have ranged from zero,
where the contract required the vendor to cover federally mandated changes with
several hundred dollars of software modifications to thousands of dollars where
older software had to be replaced because that version would not support NPI
and it had to be replaced in toto.
As of December 2006, none of our members had reported the testing with
clearinghouses or health plans has been initiated. The outreach that MGMA has
done over the years has been significant on this issue to try to make our
membership aware. There have been articles through our MGMA magazine starting
in the year 2000. There have been e-mails through our Washington connection, a
system which has continued to go on. We have had webinars to enhance our
practice managers so they know how to get the NPI, what they need to do to
prepare to use the NPI. We have also had face to face sessions at the national,
regional, state and even local levels, and all of these forums have been used
to impart to our membership how important the NPI process is.
The prolonged delay of the data dissemination policy and the resulting
inability of medical practices and other authorized entities to access the NPI
database is having an extremely detrimental impact upon our ability to meet the
regulatory deadline. In order that implementation of the NPI occurs in a timely
and efficient manner, publication of the data dissemination policy along with
access to the database should be expedited.
Therefore, there is uncertainty about how can share NPI with whom. The fear
of litigation if you disclose an NPI has surfaced in the last few months. The
NPI was intended to simply identify a unique provider. It now seems to be going
to be used as a secret number and concerns about fraudulent use. However, to be
successful, the identifier has to be known by providers and health plans. CMS’
motto, get it, use it, share it seems to be changed to, get it, use it, share
it, but be careful you are not sued. CMS’ delay in the release of the data
dissemination policy has prevented medical practices from developing crosswalks
and implementing other related business decisions because they do not have the
identification number of other providers. Because of this lack of publication,
some of our groups have started to look at ways that they might assemble their
own type of databases that could be shared, but the issue about who can share
with whom has become a problem.
It is clear that without the NPI, practice management and billing systems
cannot be tested with clearinghouses and health plans. We also are concerned
that the data dissemination policy that will be released by the CMS will not be
final and will not be implemented immediately. We are concerned that there
might be a comment period and then re-release of the regulations, which
forestalls the certainty of how to access the database even longer.
An additional data dissemination issue involves obtaining referring
physicians. Currently referring physician files have been developed over the
years by obtaining them as needed by looking them up in the UPIN directory.
With the move to NPI, all practices will have to call, e-mail, write or fax all
of their referring physicians to obtain those NPIs, creating a massive
administrative workload and hassle. Can this burden be decreased?
P> No one can dispute that an NPI is needed on a claim form for the provider
service. However, many practices may not have the referring physician’s NPI. Is
it fair to reject a claim because there is no referring physician NPI? In these
cases, the physician may not have been enumerated yet, or he may not even have
to obtain an NPI.
Access to a central database similar to UPIN registry is still the best
solution. A regional provider like Wake Forest has approximately 10,000
referring physicians in our existing database. Gathering these one by one is
not simply feasible. Health plans are dependent upon the UPIN to identify the
rendering provider in the same way the providers are dependent upon it for the
MGMA is concerned the data dissemination policy will not include the
information to assure the industry has the direction required to implement the
NPI expeditiously. It is critical that authorized individuals have the ability
to actively search the database. We are concerned that if the database is
restricted to just name and NPI, that this will be a tremendous disadvantage
for those who query the system. Searching only by name, for example, would no
doubt lend to numerous John Smiths and the potential for identifying the
Finally, authorized providers themselves must be afforded the same access
rights to the database’s health plans. Providers in order to submit claims need
to be able to work with other providers who refer in order to participate in
the patient’s care. Even a database query by UPIN requiring the name, practice,
address and NPI would be extremely helpful.
MGMA recommendations. Medicare and private plans should be permitted to
continue accepting legacy provider numbers in order to avoid cash flow problems
over the implementation period after May 23. In 2005, WEDI recommended that the
dissemination system be available July 15 of 2006. Having failed that, WEDI
recommended that we continue to use the legacy number for 12 months after the
We agree with WEDI, although we are concerned about the 12-month cutoff. We
would respectfully submit that maybe this committee, NCVHS, would continue to
monitor industry compliance and recommending the ending of the contingency plan
only when the vast majority of covered entities are fully compliant through
Most importantly, this contingency plan should not require providers to
submit both legacy identification numbers and the NPI. To craft the contingency
plan in this fashion would likely result in significant claims submission
difficulties for providers. In addition, any contingency plan should still
encourage providers to obtain NPIs by the May 23 deadline.
Finally, significant notice should be sent to the industry before the
contingency period ends.
NPI exchange guidance. Since these rules are silent on the exchange of NPIs
other than requiring that the covered provider must disclose NPI to those
needing them to conduct standard transactions, it would be very helpful if CMS
would publish a guidance stating that the exchange of NPIs among covered
entities is allowed without special permission from the owner. The concept
would be similar to that of the exchange of protected health information for
purposes of treatment, payment and operations.
The use of OTHOO for referring physicians. To avoid the potential of
rejecting claims, CMS has permitted under the UPIN side to use an OTHOO as a
default, and we would request something similar be used in the NPI situation.
As we have said, in the current NPI system, the provider has the ability to use
this. They also have the ability to use an RESOO for residents who many times
would not necessarily have an NPI for the referring physician. Allowing this
after the NPI compliance date will mitigate the problem and protect cash flow.
CMS should expand provider educational activities. It is imperative that
CMS augment the level of education. Targeting certain groups as small provides
will help areas in expanding their current face to face conferences, also
coordinating with the industry trade associations.
Some sectors are now just hearing about NPIs, as we understand. In a
recently meeting of critical care access hospitals, 80 attendees were not sure
they understood what NPI was about, and were completely unclear that there
would not be a UPIN type registry.
CMS should expand vendor educational activities. As the industry found out
when we did the HIPAA electronic transactions, providers and others must rely
on non-covered entities to come into compliance. CMS should work closely with
the vendor community to insure that they are fully apprised of the regulations
and what to expect from their covered entity customers.
Recognition of future regulations that must have staggered compliance date
is also important. Significant industry migrations is afoot, such as the
proposed transaction from 5010 for the X12 837, the proposed electronic
attachments and potentially transition to ICD-10. It should first require
health plans and clearinghouses to have an implementation date, and then
providers to have an implementation date. I think we learned this quite well in
our earlier HIPAA transactions implementation.
Continue identifying the roadblocks and difficulties facing providers and
other entities as they work to try to be compliant. If we don’t learn from our
past, we are doomed in our future. The NPI implementation process needs to be
identified and applied to future standards to insure that implementation of any
of those provisions are as cost effective as possible. With literally billions
of dollars at stake, including savings for both Medicare and Medicaid, the
federal programs should identify implementation roadblocks and achieve
compliance as quickly as possible. Every day without the benefit of
administrative simplification results in the loss of millions of dollars of
savings. if the federal government sends a negative message to the industry,
the release of administrative simplification standards are significantly
In conclusion, MGMA is highly supportive of the development and use of
national standards for the health care industry. Standards for collection and
transmission of electronic health data will improve the quality of health care
while at the same time lowering the cost of providing health care to the
While MGMA is confident that full implementation of NPI will ease
administrative burdens and facilitate improved data exchange within the health
care industry, roadblocks exist that must be addressed before full
implementation can be achieved, and a contingency plan is now required.
We appreciate the subcommittee’s interest in this important topic, and
thank you for your time.
MR. REYNOLDS: Thank you. Frank.
MR. KYLE: Good morning. Thank you for inviting the American Dental
Association to speak this morning.
Since I am not personally the expert in this area for the Association, I am
sorely tempted to read my testimony, which has been vetted through the experts
in Chicago. But if I understood your questions, Harry, you want to know whether
dentistry is going to be ready, and if not, why not, and what recommendations
we would make and why that would make a difference.
MR. REYNOLDS: There you go.
MR. KYLE: So I will try to answer those questions rather than read my
testimony, although I think the basic testimony we have provided to you would
also end up with the same result.
The short answer to the question, will we be ready, is, I think we will be
ready as far as dentistry obtaining NPIs or dentists obtaining NPIs. Based on
some preliminary data that we have, about a little over 86,000 had their NPIs
The ADA represents about 72 percent of the practicing dentists, that is
153,000, and we estimate that that represents at least 58 percent of the
practicing dentists out there. However, we also estimate that only about 70
percent of those dentists actually use an electronic claims transaction. So if
you use that kind of number, it could be as much right now as 85, 86 percent of
the dentists are already prepared to use an NPI. And we estimate that there
will be some continual growth December to May.
Whether or not we will ever achieve 100 percent, who knows, but we do think
that dentists will be ready to use the NPI. The bigger question we have is
whether or not we will be able to use the NPI in an expeditious fashion to file
claims and receive payment. You have already identified that as a concern you
have surfaced, and it has already been mentioned here by other testifiers.
We have some concerns about how that is going to happen. We understand that
there is something like — from about 35 payors and vendors that we know about,
each one has a slightly different process in how they are asking their
providers to provide the NPI, whether they are going to accept legacy numbers,
all that kind of information. So assuming that a dentist would have more than
one payor that he would have to deal with, he is going to have to deal with
multiple instructions on how to comply, how to make this work. To the ADA’s
knowledge, there has been very little testing. I think that has already been
testified to, as to whether or not the payors and the vendors are ready to
accept the NPI, and will they be able to do the work they are supposed to do
come the 23rd of May. So I think that is the bigger question.
We have had some members who have complained about the process of obtaining
an NPI. We outline some of those in the testimony, and I won’t read them all.
Just as of Monday, I had a conversation with a dentist, and I happened to ask
him about NPI and he said he didn’t think he needed one because he didn’t
accept any federal insurance programs. You know that that is not the case, but
that was his level of confusion.
The ADA has published a number of articles in our News. We have done a
number of outreach efforts through the profession, and I outlined all that in
the testimony, trying to reach our member dentists, and we will continue to do
that probably up through and after the 23rd of May. But still there is going to
be some confusion out there, and this has already been identified. The process
has confused some of our dentists, but 86,000 have already been able to work
their way through it.
What are our recommendations? We looked at the WEDI recommendation for the
contingency plan of the 12 months of dual usage, NPI and legacy numbers. We
thought that was a good plan, and we agree with the WEDI recommendation.
Why would that make a difference? I think it makes a difference because
while the dentists may be ready to provide the NPI, we are not sure that the
payors and the vendors will be able to use the NPI, and this would allow a
seamless transition and not delay payment of the claims and processing of the
claims in a timely fashion. I think that is our members’ biggest concern.
Like I say, there is some more stuff in the testimony that I won’t bore you
with, and I would be happy to answer any questions.
MR. REYNOLDS: Thank you. Mari.
MS. JOHNSON: I am Mari Johnson. I am the Director of Federal Affairs of the
AMA. I am tempted to read the testimony, but I think I can probably point to
some of the things that you have asked about.
I am going to echo some of the concerns that you have heard, which is that
a contingency plan is needed. It is hard for us to determine how many
physicians actually have their NPI. We have shared data from our master file
with CMS, but unless that data is shared back with us by state and by specialty
as far as how many physicians have the NPI already, we can’t make a comparison
to how many are out there who do not have it. So that has been a little
challenging as far as outreach.
We have done outreach. We have things at our website as well. We have
published internal memos, similar things that have been mentioned today. We
have listserves, so on and so forth. What we think would be helpful as far as
outreach would be to have a technology assistance line similar to the one that
was in effect in the transaction and code set period, prior to and through
2003. Right now, the NPPS folks can only answer certain questions like, can I
get a copy of my NPI documentation, but if they have a technical question they
are told that they are unable to answer those. So that has been a challenge. I
think something like that would be useful the closer we get to the deadline.
I think if that data could be made available, we could also start targeting
things a little bit better. In fact, I think we could do a lot better if we had
a little bit more disaggregated data. So I am hoping that will be forthcoming
soon. I know that CMS has published reports on the website, but they are only
broken down by type one and type two. Type one could include physicians and
dentists and other providers, so it is hard to get a sense.
As far as concerns with the contingency plan, we would like to echo the
comments MGMA made with regards to the need for having the ability to report
legacy and/or NPI numbers. It can’t just require both. It would severely hamper
physicians’ ability to get their claims processed. I’ve got to tell you, a
number of them are already feeling the fear that they had back in 2003 with
regards to cash flow and claims interruption. So any contingency plan that is
put into place will need to take into consideration the ability to continue to
allow legacy numbers until such point that the payors and other providers are
able to start moving things along with both.
We support the 12 months at a minimum time frame that was outlined by WEDI.
As people may remember, in 2003 when the transaction code set deadline came
about, that was already a one year extension. That was when the contingency
plan started, and it wasn’t terminated for claims until 2005, in October. Then
a year later again it was terminated for remittance advice, and it is still in
place for the other transactions. So it is definitely something that over the
next year. We think the physicians should have their NPI by May 23, 2007, and
then use that time forward to work toward implementation with the rest of the
health care industry.
What other questions? I touched on outreach, the need for contingency. I
think I could mention some of the specific physician concerns that we have
heard with regards to privacy.
Physicians are concerned because this is a unique identifier with who will
have access to their number. It is different from the unique billing numbers
that are out there today. It is going to be on every single claim, and it will
be accessed by numerous individuals. Physicians have supported access to other
entities who need it, meaning other physicians, other providers, payors, those
people who are conducting health care operations. However, we do not support
widespread access to the public at large. We do believe that any lookup
directory which is needed should be restricted to the UPIN elements that are
currently made available.
I think I have hit the high points. We do have testimony. In the interests
of time, I won’t read anything further. Do you have any questions?
MR. REYNOLDS: We’ll ask questions. Well done, thank you. Thanks to all of
you. In one way or the other, each of you touched on the four questions, and so
now we get into what we need to ask.
I know Jeff has a question, I have got a few. I’ll start making a list.
MR. BLAIR: Thank you, everyone, for coming prepared and coming with your
testimony. I don’t know if you remember Harry’s four questions. As I listened
to what you said, I tried to mentally organize it back into those four
questions. It would help me frankly if we go to that structure a little bit. So
I would like to repeat those four questions and ask each of you to explicitly
answer them, because they build on each other, and it will make it a lot easier
for us to make an intelligent, helpful wise decision. So if you could make a
The first question is, for each of the organizations that you represent,
what percentage of your membership will be ready with an NPI? I’m not talking
about crosswalks yet, just, will be ready with their NPIs, level one and level
two, by May 23. That is one, a very simple question, what percentage will that
MR. REYNOLDS: Let’s do them one at a time.
MR. BLAIR: Okay, let’s do them one at a time then.
MR. REYNOLDS: We will just go in order again. Carole?
MS. MAGOFFIN: I would say roughly half or less.
MS. RAINES: From an HCA perspective, all of our facilities, physician
practices will have obtained NPI, 100 percent.
MR. DAWKINS: If I might put this in two time frames, the larger practices
will be closer to 80 to 90 percent, smaller practices will be in the 40
MR. KYLE: It is difficult for me to tell you between level one and level
two. That is one of the questions that members have asked us about, do I need a
level one, do I need a level two. I am a solo corporation, do I need a level
two, that sort of thing.
Based on our preliminary information that we received from CMS, 86,000. We
think that is at least 58 percent, could be as much as 86 percent. By May 23 I
think the vast majority, 99.9 percent of the people that need one are going to
have one. That is not going to be 100 percent of all dentists, but that is
going to be 100 percent of the people that need one.
MS. JOHNSON: To repeat what I said before, this is a real challenge for us
in determining how many have their NPI. It is impossible for me to even
speculate, but I think if we were able to get the disaggregated by specialty
and by state, we would be able to pinpoint that by our outreach.
One thing I also didn’t mention but it has direct correlation to that,
Medicare has made the business decision as a covered entity to require paper
billers to obtain a user NPI. While other payors may or may not decide to do
that, there is a large unawareness among those who are not required under HIPAA
to comply with NPI but will be under business decisions of payors. So I think
that there is another bucket that we need to consider as well.
MR. BLAIR: What percentage can you give, as an estimate?
MS. JOHNSON: I don’t have an estimate for the paper billers. I can go back
and take a further look at that for you, but I think that would almost be even
harder to speculate. I could work off of numbers as far as how many paper
billers there are, and try and figure that out. That is just an additional
concern. But as far as electronic billers, it is very hard to know.
MR. BLAIR: Let me give the follow-on, question number two. Of the
percentage that will not be ready, could you give us the one or two or three
principal reasons why those groups will not be ready by May 23, 2007. We want
to try to focus in on those and try to get crisp, clear delineations of those,
because frankly we are going to go on to questions three and four and these all
build on each other.
So I will repeat the question. Number two, for those percentage that won’t
make it, what will be the principal reasons that they won’t make it?
MS. MAGOFFIN: I am sure we have no data on that, but again, since everybody
else is guessing, I think one would be lack of awareness or the feeling that it
doesn’t apply to them.
MS. RAINES: Again from an HCA perspective, we believe that we will fully be
enumerated both for type one and type two providers.
MR. DAWKINS: I just want to clarify the question. When we are asking this
question, we are answering that they will have them, not that their claims can
be processed and paid with them. To me those are two different things.
MR. BLAIR: Correct.
MR. REYNOLDS: But I think we are actually looking for both, because
remember, May 23 is the due date for the whole thing.
MR. DAWKINS: I understand. What I am reaching for is having it and being
able to get your claim paid is two different things. I would almost say make
that another question, because it is hard for me to fold the two together.
As far as the ones that would not have them, I think it is lack of
knowledge or feeling like it doesn’t apply for them, you are a paper provider
and you need to have it, and those kind of things.
MR. KYLE: Again, we have had some dentists that have called the ADA,
confused about the process. They don’t know whether they are a type one or type
two. They have had some problems with obtaining the provider taxonomy
information or getting to the right code, they don’t understand that very well.
Again, as I said before, we have had anecdotal type information that says I
don’t really need it even though maybe I do need it, but they just don’t
understand that in spite of our best efforts.
I’m not sure that there is any one overwhelming cause of failure to get an
NPI at this point. I think there is a whole litany of these sort of issues. I
don’t know if that helps or not.
MS. JOHNSON: To echo what MGMA had said earlier, I also agree with the fact
that it is going to be hardest to get to the smallest physicians. Those are the
ones. I agree that the larger group practices are going to have a greater
awareness. So a reason for not having it may be one, they are unaware, two,
perhaps they are a paper biller and for a payor’s business practice like
Medicare, who has decided to require the NPI, they may not be aware of that. I
know many are not.
I would also say that Medicare’s enrollment policy now is such that if you
are enrolling for the first time in Medicare or making a change in your
application, you must have your NPI first and you must supply documentation. So
you may have your NPI, which is feeding the number of physicians or other
providers who are obtaining their NPI. However, if you are unable to get your
enrollment application process, then you are not submitting any claims.
MR. BLAIR: Question number three builds on the answers that you have just
shared with us. For those that won’t make the date, you have given us your best
estimates, of the principal reasons why. Just echoing back what you have told
us, some of it is that some of these folks are not aware, others are education,
others that would be in paper form, others that they are small or rural
practices. Echoing the ones I heard at the top, there may be more, but between
now and May 23.
The third question is, what can be done to help those folks so that they
can get their NPI by May 23, what needs to be done. I’ll put it in two phrases
maybe. What needs to be done, and who are the principal agencies, whether it is
the private sector, professional associations, the federal government,
whatever, what needs to be done between now and then for those folks to be able
to make the May 23 deadline.
MR. REYNOLDS: We will go in the same order, but if you don’t feel you have
a comment, then that is fine. I don’t feel it a necessity to drag something out
of everybody each time. I want you to feel comfortable that if you have
something to add, please do. We have heard your testimony, we have heard what
you said in each category.
MS. MAGOFFIN: I just want to reiterate that I don’t think it is possible to
get a sufficient number of minority providers that are a large part of
physician office practices. That is a big concern of ours. We know that
physician office practices by and large are all paper. So getting those numbers
would be helpful.
We have historically created a data set where we were able to target all
minority physicians in the U.S. Doing that by geographic region might be useful
to help the cognizant agencies reach out to those areas that are most
noncompliant at this point. But you would have to link various sources of
information to be able to do that, that the government has that we wouldn’t
But that would be one potential approach. I do think this targeting is
going to have to happen. The message just isn’t getting through.
MR. REYNOLDS: A clarification question. So basically your statement is that
many of the providers that you represent are not electronic, but with the new
Medicare requirement on paper claims for the NPI, they would still have to get
NPI numbers, is that correct?
MS. MAGOFFIN: Right.
MR. REYNOLDS: Was that a fair statement?
MS. MAGOFFIN: Yes.
MS. RAINES: The only thing I wanted to add is, to obtain the NPI to become
enumerated is an extremely simple process for a provider to go through. Our
greater concern as we have already addressed is being able to obtain the NPI
for the other providers, where those numbers have to be provided on the claim,
and then the level of confidence needed from the health plans, both federally
and non-federally funded.
The industry at large is ready to implement. The obtaining the number
itself is the most simple aspect or the most simple piece of this. Claims
testing, which we have already spoken to, most certainly access to NPPES,
particularly from a hospital perspective, where we have to have the physician
NPI numbers, is a great concern.
MR. DAWKINS: I think as far as associations, all of us will continue to
send information. But I think what you are seeing is the old 80-20 rule. We
have probably gotten through our communication 80 percent. What we are dealing
with is the 20 percent that we haven’t gotten to.
None of us have a list of all of the physicians and can check them off
whether they have got an NPI or not. About the only thing that I can see that
you could potentially do is for CMS to pull their carriers or whomever and ask
them to determine, since they are all having to build crosswalks, to determine
the ones that they do not have an NPI for so far, and potentially target those
groups of individuals. That might be extended even to the Medicaid program
also. You could ask other payors to do it too, but I think you would get
another 75 percent of that 20 percent just dealing with Medicare and Medicaid
because of the vastness of what they do.
MR. KYLE: You asked the question of what needs to be done. I’m not sure
what needs to be done, but I think that there are some things that we may be
able to do.
Obviously as I mentioned before, we are going to continue to promote the
NPI in our publications. That reaches a large majority of the dentists out
there. However, there may be other dental organizations that we can go to and
try to disseminate the information through those organizations. That may be of
some help in getting the information out.
But other than that, I can’t really think of anything else that needs to be
done. I think we have done what should have been done to promote obtaining the
NPI to this point.
MR. REYNOLDS: Mari, anything to add?
MS. JOHNSON: I know a significant amount of outreach has occurred through
WEDI and through ML and Madders articles. However, I’m not sure every physician
has the time every day to read ML and Madders article that comes out.
I think that increased targeted outreach, too. If we had more pinpointed
data, we could get down to the local level better, and that could be through
local conferences, having CMS piggyback on existing outreach events that are
already occurring between now and May 23. That is a strategy that is often
One other thing that I think would be helpful is to make sure that when a
physician does call an enumerator NPPS and needs a copy of their documentation,
assuming that they are able to verify who they are through key identifying
pieces of that information, they should be able to get it, if someone else
applied for their NPI on their behalf, like say a former employer. So don’t put
hurdles in their way.
That at least would help with the Medicare portion, because without the
documentation that you have in your NPI, that could stall things further. So
allowing the doctors to directly get that documentation could speed things up,
because Medicare enrollment takes several months.
MR. REYNOLDS: Jeff, do you want to follow up on this third part? Okay, go
to question four.
MR. BLAIR: Yes. I just want to echo back a little bit what I am hearing. I
know I may not be complete, but I believe that Denise is taking notes.
Some of the things that I am hearing that could help us to close the gap
for the percentage of health care providers that don’t have their NPIs yet are
continuing emphasis on education, the availability of the NPPES, the outreach
not only to the traditional membership organizations, like Frank, you mentioned
there are other dental associations and maybe you could extend to those or
maybe to minority groups, to try to get the word out through other avenues of
Those were the ones that at least I was able to retain in my memory as you
were giving your answers, and there may be more that Denise has captured.
Denise, was there something more I think I overlooked as I summarized that
answer to question three?
MS. BUENNING: I think those are the broad areas. There are certain
recommendations within each of those. For example, I know that Mari had
mentioned getting a technical hotline for assistance, so that falls within
outreach and education.
MR. BLAIR: Excellent, thank you. I am technically challenged, the people
next to me, help me out.
The fourth one is a bit of a challenging question. By the way, I want to
thank you for all of the answers that you have given to help us out so far,
because they are not always straightforward answers to these questions.
The fourth one gets to the area of, if we come to the conclusion that it is
not realistic for us to be able to close the gap, if that happens, and if there
is a recommendation for an extension to the deadlines, either partially or in
whole, it raises the fourth question.
The fourth question is premised on the fact that we have had two years to
try to get the industry ready. There has been tremendous investment by
professional associations, trade associations, health plans and providers
during these last two years to educate the health care community on the need to
go through the enumeration process and to do testing; two years.
Why should we have confidence that something is going to change if we wind
up saying we will give things another year? That is the question.
MR. REYNOLDS: I’d like to add one little segment to that. If your
recommendation, which I have got three of you recommending the 12 months or
more when I did a quick calculation, what is the structure of that? Again, we
would be sending the message to the industry that the May 23 didn’t matter, and
now we are going to take X amount of time.
What do you see as a structure to that, that makes it a recommendation that
is a real recommendation, other than just another date? That is what I’d like
to make sure we understand.
MS. JOHNSON: I would say that we are recommending a minimum of 12 months
from the time that physicians and other providers have access to the numbers.
The data dissemination numbers have not been published to date, and the entire
industry has been thwarted.
The implementation, in case I didn’t underscore that, that has been the
biggest barrier to moving ahead. Physicians are afraid to share their NPIs with
other provides, with the payors. Without clear direction from CMS, we are going
to continue to be thwarted.
MR. DAWKINS: I would say that piggybacks the question I was talking about.
If you are talking about being ready to process, that is a different story than
No one has a problem with, you have got to have a provider number to put on
a claim. I think you heard in our testimony, and this is true again still, that
most of our members have not tested with any of the payors about the transition
as of December. That is an awful late time.
So it is a combination of provider and payor being ready, because payors
had to make changes to their system. This affects cash flow. We are very much
interested in them getting it right. We want to work with them, they want to
work with us. There is nobody that wants to delay this, but the fact is that
you don’t have it.
The other side of it is this referring physician issue which is a Medicare
requirement, which is a Medicare requirement, which will reject the claim if
you don’t have it. Without the dissemination issue, then you are stuck. That is
a cash flow you can’t get beyond.
As I said in the testimony, in the UPIN situation there was a default code
that you could use if they didn’t have it. I understand referring physician is
important for CMS. I know it goes on the subscriber’s EOB as to who
requisitioned the test, and they do some things behind the scenes, but quite
honestly it is not — from the provider’s perspective, it is not as important
an issue to have the claim paid as the rendering NPI is.
So to hang up a claim based on what I call secondary data, which most other
third parties don’t require and is not necessary, that is the issue that is
throwing us, because the dissemination as we said has been promised for
probably 12, 18 months, and we are still here today not seeing it. Still if we
see it, we don’t know if we can use it.
This was very much the same case when we looked at getting the NPIs and
whether you could do it electronically in a batch mode. It took almost until
October of last year, I believe — I could have that date wrong so don’t quote
me on that — but it was quite some time to do it. It looked like the
requirements for getting the physician to sign every time you sent in a change
was going to be prohibitive to that process. It is the process of getting
people to use them.
It goes back to different time lines for clearinghouses and payors versus
providers. We continue to lump all of them together, just as we learned the
last time. It is very important to have two different time lines.
MS. RAINES: Just quickly from the Federation’s perspective, we completely
concur. Very well said, the comments that were previously made. I think
industry once they got access to NPPES — we would strongly recommend a six to
12 month extension once we got access to the NPIs for those referring
MS. MAGOFFIN: I wouldn’t say that at this point two years was enough time.
Clearly it demonstrates that two years was not sufficient time for all that
needed to happen.
MR. BLAIR: Clarification. You indicated to us that you felt that once the
NPPES is available, that you thought it was reasonable that a deadline of 12
months from that point was reasonable, is that correct?
MS. MAGOFFIN: Yes, that is correct, at a minimum.
MR. DAWKINS: I would say to monitor how it was implemented. It could be
less or it could be more, that is okay.
MR. BLAIR: So if the NPPES is available February 1 of this year, you are
saying it is 12 months from that date, is that correct?
MS. JOHNSON: It is all predicated on what comes out in the data
dissemination notice. Assuming that appropriate access is granted to the
physicians and providers, yes.
MR. BLAIR: So it is 12 months from the availability of NPPES.
MR. DAWKINS: And assuming that it is similar to the functionality we have
with the UPIN, because functionality makes a difference.
MR. KYLE: Maybe I don’t understand everything here, but it seems to me that
maybe you are asking the wrong people that question. Our concern is the ability
of the payors and vendors to be able to do the crosswalk between the legacy
numbers and the NPI. We don’t have any control over that.
So our recommendation is based on WEDI’s recommendation, which we believe
is a studied recommendation on their assessment of this to happen. If the
payors come up here and say we can’t do it in 12 months, then I think you have
to listen to them.
MR. REYNOLDS: But again, the question is still on the table. There is May
23. Remember, everybody gets a shot here today, everybody is going to have an
opportunity to have what they are going to say. But I still haven’t heard,
which was part of the question, what is the process after May 23.
Larrie, I’ll go back to one of your comments. Probably in the previous
HIPAA, the payors had to get ready and then the providers. In NPI, the
providers have to get ready and then the payors and others, because they have
got to pick a number. So then the next 150 panel will probably be back the
other way, and then ICD-10 is a tossup and everybody has to go together.
So I think the question still is on the table. There is a federal
regulation that says May 23. If we recommend moving that in any way, what is
the process? Remember, this is your shot in the barrel here. What is the
process that should go on to make sure — 12 months or later is a great
statement, but if you look at some of the 5010s and you look at the rest of our
hearings, people are going to say let’s hurry up the other standards. We are
going to start stacking these up like airplanes again, like I mentioned.
So we have got to figure out what is the process that each of you in your
portion of the segment wold see as viable to get this thing done at some point
and how it would be measurably done, and how somebody would be able to evaluate
and how we would be able to say to the Secretary, by the way, this is not
forever and ever; we have got some process to recommend to you.
MR. DAWKINS: I guess I would say — let me try to take a shot at that,
because it is a wide open question, but I’ll try to bring it out.
One is what we just said, the dissemination process has to be done. It has
to have some type of functionality that is similar to UPIN. The second thing in
my mind is, CMS has to decide who you can share this with. Right now if a
hospital is doing an Xray and they pass that out to a physician who is going to
interpret that Xray, they can’t give the physician the NPI of the physician
that requested it. That other physician will have to go get it himself. That is
a real hassle and inconvenience the way it is.
As we said, we believe NPIs ought to be able to be shared between trading
partners, business associates, anybody that is doing business, similar to the
way we do the HIPAA rules. There shouldn’t be any question about that, that you
can share those. We certainly do not want to create a fraud issue, but if
anyone is believing that protecting that NPI is going to cut down on fraud, I
think that is not necessarily where you need to be putting your boat in that
MR. REYNOLDS: So are you positioning that under treatment, payment and
health care operations?
MR. DAWKINS: That is correct, treatment, payment and operations.
The third thing was that we need to be sure that clearinghouses are a key
piece. This was our Achilles heel last time, and some payors were an Achilles
heel last time when we did transaction sets. But they need to be ready before
the providers can do the exchanges and do the testing, so that we can have a
Those are the three things that I see need to happen in that 12 months. I
would hesitate to say what kind of time you can put on that, but if you ask
what is the structure, clearly the dissemination so we can get this thing up or
down. Or CMS can decide they are going to do a temporary hold on deferring and
give you a default for that one and not deny your claim if you don’t have it
The other one would be how we can share so we can disseminate these things.
You have got to remember, this dissemination issue is not an issue a year from
now. The fact is, we have a 10,000 name referring physician file just as
hospitals do and every practice does, and we have got to go get the NPI for
those so we can process our claims. We are already looking at the services that
were requisitioned a year ago for people after May 23 to see if we have those
referring physicians NPIs so that we can process and get our claims paid.
We are having to do all of them at once. We built this over ten years of
adding a few hundred a week, whatever the case would be. So that is part of the
problem. Once we get down to a normal workload, that is not as much of an
The other thing is making sure our payors will take it, and their systems
have been tweaked to the degree that they can get our payments back, and we
don’t have the exchanges. In my mind, and somebody else in the room can correct
me if I’m wrong, most payors that I know of are doing a crosswalk from the NPI
to their legacy number. They are not what I will call adjudicating based on an
NPI. They are changing it back because their systems are big and large, and to
make those changes would probably be not cost effective for that payor.
We have no problem with that. We just want to make sure the crosswalks are
right. You can’t do that unless you exchange information and test your claims.
MR. BLAIR: Just to help you understand a little bit of the background, we
don’t want to push any group to do things that are uncomfortable, unfair,
excessively expensive or things they can’t do, so it is not that intent, to
meet an arbitrary deadline.
But this particular thing of accepting the NPI is within a broader context.
There is a whole array of issues with respect to moving the country to the
adoption of electronic health record systems, electronic describing systems,
the Nationwide Health Information Network, a whole array of things which
require that we move to interoperability.
If we have problems with the NPI which compared to a lot of those other
standard requirements, this is simple, if we can’t do this in two years, there
is going to be a lot of folks that are going to start to raise questions as to
what will it take for industry to become more efficient, improve quality,
improve patient safety.
So this is just to give you a little bit of the backdraft of how do we
create the right balance where the industry has enough time to do the right job
and get everybody on board. Tomorrow we have folks that are testifying that are
saying this entire process is taking too much time. We can’t afford to take
years and years to make these transitions.
So I’m sharing that with you so you sort of understand the background.
DR. FITZMAURICE: I want to take it in a little different direction. It
wouldn’t seem hard to generate a national provider identifier, to accumulate
information for it, but it is hard, because once you have got this body of
information someplace, then you have to be concerned about people doing bad
things with it.
So I want to take this to the arena of privacy and confidentiality and ask
you what are your privacy and confidentiality concerns. Let’s say CMS or HHS
should permit public access to the NPPES. I’d like to know what is the current
UPIN policy? Can anybody get access to that database? What do you think might
be done with this information that might be harmful? Then how could those with
a legitimate need to this information be identified?
MR. REYNOLDS: Anybody.
MS. RAINES: It is my understanding that there is no intelligent built into
the ten-digit NPI. There is virtually nothing that you can tell about that
provider or that provider type by simply having access to the number. Unlike
from a hospital perspective, unlike from the Medicare legacy unique identifiers
that we have today, you can tell the physical location, the state of the
provider, you can tell what type of provider it is.
So if nothing else, from a hospital perspective, we probably even have a
lesser sense of security or confidentiality issues with NPI than we would from
the legacy numbers that we use today. There is virtually nothing that you can
tell about that provider by simply looking at the ten-digit number.
DR. FITZMAURICE: Remember, I am talking about access to the NPPES, which
would have additional information than just the single number.
MS. RAINES: I think until the final rule is published or the policy is
published and we understand the extent of the information that would be
available, it is difficult to respond to that.
MS. JOHNSON: The AMA covered this pretty extensively in our testimony. I
tried to stay on target with the four questions. But we have heard from a
number of physicians that, this is a unique identifier, and there are concerns,
which is why we have advocated for limited access, meaning access to those who
need it to conduct their health care business, payors, other providers, other
physicians. But should your neighbor next door have it? No.
So we have advocated no. We also believe that would help from the sale of
the number, as has happened with the DEA number, which is publicly available on
the Department of Commerce’s website, for sale through databases. So we have
touched upon that in our testimony.
DR. FITZMAURICE: So the fear is that somebody might masquerade as that
MS. JOHNSON: Absolutely. Identity theft, there were a number of instances
that were reported in the media. What isn’t as widely reported is the cases
where the physician’s identity is compromised. The identifiers are on every
DR. FITZMAURICE: And on prescriptions too, in many cases.
MS. JOHNSON: There is discussion about putting the NPI number. That is
another issue, but the DEA number, yes.
MS. MAGOFFIN: I know there are really serious confidentiality concerns, but
I think from our perspective and looking at the research that needs to go on
with patients, which we don’t talk about a lot, I worry that we will go the
other direction and make it all so secret that there won’t be any ability to
use these data for research to track the real goal for implementing a national
health infrastructure. We can make this so cumbersome and these data so hard to
get at that it just becomes impossible to do the kind of research and
surveillance that is required.
So I think we have to speak out on the issue that some attention has to be
paid to the fact that the point of this whole system is to increase the quality
related efficiency of our system.
MR. DAWKINS: If NPPES contained some confidential information about the
physician, it should not be made public, such as the social security number.
That would lead to potentially identity theft.
The UPIN system, and somebody may know better than I do, but I am pretty
sure it is publicly available, that you can key it up and it gives you the
name, the UPIN and the address. We think that limiting it to that information
doesn’t particularly cause an overwhelming fraud issue. The people that are
going to cheat are going to cheat.
I don’t think CMS is going to base their detection of fraud based upon
using an NPI. If I want to get an NPI, I just say I am Dr. So-and-So, I need
your NPI for a claim, and more than likely that practice is going to give it.
They are not going to make me send a letterhead letter with a notarized on the
bottom to prove who I am. That is not efficient.
What we have here is a balance between the privacy and the efficiency of
processing the system. NPI is needed for the processing of the system. We need
to keep it as benign as we can. Certainly nobody would say public access to the
NPPES would be the appropriate thing to do. But also, there has got to be
access so we can move these numbers around freely among providers.
As an FBI agent told me about ten years ago when I started working in
compliance, he said, it is amazing to me that the people I am prosecuting for
health care fraud were the ones that were in the savings and loan fraud not too
many years back. So the crooks are going to move around. But I don’t think the
vast majority of the 95 percent of providers that are going to play by the
rules should be penalized because of the five percent that potentially abuse
the system. I think we all have to stop the fraud and abuse, but there are
other ways to do that other than protecting the NPI to the degree that you
can’t use it among the people that need to use it.
DR. WARREN: Mike asked part of the question that I was going to ask. I was
really amazed when I read your paragraph in your testimony about the selling of
DEA numbers by the federal government.
So to add on to what Mike had mentioned, what would you like for CMS to do
in this final rule and their policies to ameliorate this situation? Would you
suggest to CMS that they write certain policies and procedures in this, since
the rules have not been put out? What would you like to see them do to protect
the privacy of people holding the NPI, and yet as you said, not make it too
I do think we are at a Catch-22. All of you have said at one point that
people are not willing to put themselves at risk for identity theft. You hear
about it all the time on TV news, and it can happen from a lot of places. We
have also heard testimony that NPPES does not have any intelligence behind it,
so if you are able to query it, you are able to query it.
We have known with some of the HIPAA and the PHI, organizations still hire
people who don’t do as they should, and they have access to this information
and will use it in order to steal identities.
So with that, what recommendations would you like to see CMS put on access
to the NPPES?
MR. DAWKINS: I think what we would say is that it should emulate the UPIN.
The UPIN is the number we are replacing. It should emulate the UPIN as far as
what is available. That seems to work.
I’m not aware, although it is possible that somebody has stolen somebody’s
identity using a UPIN, I do not hear a lot about that, even though we know that
the UPIN file is not clean and has duplicates in it. That is one of the reasons
it couldn’t be used for this process.
So I would think that UPIN at a minimum, if CMS can allow us to use it with
our trading partners, business associates and the people we do business with
under the treatment, payment and operations perspectives as far as sharing it,
that goes a long way towards getting on with what Jeffrey talked about, about
getting this implemented.
Jeffrey, I would make one comment about that. While we have been at it two
years, I think about a year of that was taken up by CMS building how you got an
NPI. So providers in essence have had a year to 18 months to get there. Two
years? I stand corrected then.
MS. JOHNSON: I’d also like to echo that. One thing that we wouldn’t want to
see published is a physician’s address, which is often the address associated
with the NPI application. We have heard strong opposition to that.
DR. WARREN: I just want to follow up. Would you want us to recommend that
the Department of Commerce not sell this list?
MS. JOHNSON: Yes.
MR. DAWKINS: Yes.
MS. MAGOFFIN: One of our big recommendations is that zip code is on there
somewhere, because that is a way you can do surveillance without identifying.
MS. RAINES: The only thing I wanted to add, from the Federation’s
perspective, we concur with the previous comments that have been made.
The only thing I did want to clarify for this two-year window that we are
talking about, from an HCA perspective, we did wait for several months on the
details regarding enumeration to be released. That took a good six to eight
months of that two-year window. So even though you can apply individually on
the web, which is what we wound up doing, we did wait for several months . The
clock did tick for an extensive period of time while we were waiting on the
instructions for bulk enumeration.
DR. COHN: First of all, I want to thank the presenters for what I think has
been a very useful presentation, fascinating. I want to thank you all also for
reminding us. We all tend to think of the crosswalks as just a pay issue, but
for reminding us it is also a provider issue before we can get the bill out.
You had all both in your written testimony as well as in your presentations
at least vaguely referenced the issue of software readiness, in practice
management systems, hospital billing systems and dental systems, et cetera.
Yet, I couldn’t tell as you talked through this whether this is more of a
conceptual one out of 500 possible reasons why there may be problems, or
whether you really have information that this is a big issue in relationship to
readiness or a small issue that the software vendors have come forward and
provided providers with the updated systems that they really need to be able to
successfully bill using the NPI.
Do you have information on that? Do you have gestalt about the size of this
issue? Is this something that we should be aware of, or should we assume it is
pretty well solved?
MR. KYLE: In our written testimony we mentioned that we — again, this is
anecdotal information, I don’t think we have an across the board survey of the
dentists to know how many are experiencing this problem. But we have been
contacted by dentists who tell us that their current vendors are not going to
update the software, and that they need to spend, according to this, $30,000 or
$40,000 to update their systems to be able to do this.
Now, is this just one guy? I doubt it, but I don’t know how many are out
there that have had this kind of problem. I don’t know if that helps you or
not, but we do have information that indicates that this is a problem.
MR. DAWKINS: I would echo that. We don’t have the data. If you request it,
I’m sure we would be glad to ask the membership what their experience has been.
But we do know particularly that there are some vendors where if it is in their
contract, if it is federally mandated, they do it without charge.
But you have to remember, these vendors are not covered entities. They are
also out there in the business of making money, so they are answerable to
stockholders versus someone. So therefore, any changes to their systems are
expensive, and they are going to make those changes at the last possible time,
depending upon where they are as far as their revenue and budget cycles are.
So therefore, the providers are at their mercy. Some of them will do it
with a few hundred dollars. Like Frank said, we have had members report that
their system would not be supported, and their vendor was asking them to buy
the next grade. In other words, you might be on 1.0 and they will say we are
not going to support 1.0 on NPI, but if you buy 2.0 you will get NPI with no
added charge. So therefore, moving from 1.0 to 2.0 may be several thousands or
tens of thousands of dollars.
So depending upon what they are looking at from a business model, then they
make those business decisions, which I can’t blame them. I don’t like it, but I
don’t blame them, because they are in business.
MS. RAINES: If I could add also, from an HCA perspective, we have included
all our NPI system remediation with our UBF-4 system remediation in the work
that we have done internally to accommodate the new 1500 claim form.
So from a hospital perspective, we have had internally somewhere between 25
to 30 internal systems that we have had to remediate. But again, we haven’t
seen the system remediation piece as being something of vital concern. It is
more on the implementation side of the NPI.
MS. MAGOFFIN: We had understood this problem was actually well documented
for small and medium physician group practices, small practices, because you
are dealing with nothing that is uniform or standard.
MR. DAWKINS: I might add one comment. I think we do have some data on this,
and we would be glad to share it with you. But I also would say, going back to
Jeffrey’s question of putting this in context, this is going to be an issue
with each change as we go forward. It will continue to be there. Therefore,
that is part of the delay. We can’t test with our payors until our system is
ready, and if our system is not ready until the last minute, then we are hung
out to dry. We might want to test it eight months ago, nine months ago, but if
we don’t have the software we can’t do that.
MS. JOHNSON: Our members are very concerned about vendor readiness. In
fact, I got an e-mail just yesterday from a physician who was very upset out
his vendor saying he would not be continuing to update the system to allow for
the NPI, and he would have to invest in a $30,000 system, which is just cost
prohibitive for a solo practitioner.
MR. REYNOLDS: We are down to three minute. I have got one last very pointed
question. Listening to everybody, everybody has said that a single provider
getting a number is not an issue. Should on May 23 any single provider that
does not have a number be out of compliance?
I understand your idea of discussing 12 months and later for all the other
stuff. I am talking about an individual person getting a number. Again, we are
dealing with a federal regulation. We have got to answer to the Secretary. I’m
just trying to understand whether you are recommending it is all off, because a
number of your testimony made it clear and your comments have made it clear
that those numbers are available, and there is nothing holding up somebody
getting those numbers, that individual number.
MR. DAWKINS: I would say from a regulatory standpoint, that makes sense. I
understand from a political standpoint that does not make sense, because it
depends on how many people you want to make mad.
There are people out there that are not going to be do it and the question
is, are you going to penalize them and have them beating the bushes over
something that, it was CMS’ fault, it was my vendor’s fault, it was whoever’s
fault, and now my Medicare money or my payments are not coming in because I
didn’t do it.
It has to do like everything else with responsibility. There are some
people who don’t understand. There are some people who just want. I think there
is also the issue of the fact that if you draw any line in the sand, you have
to balance it with where — I reduce it to my grandson when he goes to time
out; is that going to win or is that going to not win, is it going to get the
desired results or is it not going to get the desired results.
To me, the desired results are, we want to get on with the implementation
of these other things that Jeffrey is talking about. This is one step, but I
swear, we have done it twice now, and we haven’t succeeded in what I call an
effective business model to make this work, so that everybody ends up at the
same place at the same time.
So I guess you can draw a line in the sand, is there a reason not to do
that? Only from the standpoint of how many people you want to make mad in the
MR. KYLE: This is the kind of question that gets me fired. Even if 100
percent of the dentists to have the number of 23 May, will we be able to
demonstrate that they have it, because will they be able to use it, will there
be any way to find out if it is usable on the 23rd of May. I don’t know that it
will be, from all the information that I have.
So yes, I guess technically they would be out of compliance, but I don’t
know how you are going to be able to figure out who does and who doesn’t have
it on the 23rd of May.
MR. REYNOLDS: I would recommend that the other presenters should buy you
all lunch, because now they understand what is going to happen, what kind of
questions are going on.
I would like to commend you. You were the first ones. We took you through a
rigorous process. This is obviously a difficult decision. As Larrie just said,
this is the second time we and others have had to go back to the Secretary, if
we do, and others to say the date isn’t going to work. That is why we want to
be very diligent in what we do, because then when we hear the second part of
our hearing and then when we hear 5010 and all these other things, we are
trying to learn how this industry can group itself up and make things happen
with all of us showing up at the right time.
So I truly commend you for being very open. We will vouch to any of your
bosses you shouldn’t be fired over your testimony. You were quite honest and
quite helpful. Again, writing this letter is not going to be a simple process.
Recommending what to do next is not something that those of us sitting on this
end of the table are overly excited about. However, it is our task and we need
So we thank you for doing that, and we would thank the other presenters for
doing the same thing.
We now have a break until 11 o’clock. Thank you very much.
Agenda Item: Panel II – Vendors/Clearinghouses
MR. REYNOLDS: Everybody ready to get started here again? The second panel,
you ought to feel a little better about what your requirements are. I’ll go
through the same questions for you ahead of time, make sure that you were
What we are really interested in, and we are going to build off the last
testimony, so ditto may be a word that you use a lot if you need to, and any
differentiation you can make would be helpful.
Again, the first question, will you be ready on May 23. The second, if no
what are the reasons. Third, what can we do between now and then to help people
get ready. Then the fourth is, if you have some other plan that you would like
to put forward, please continue to help us figure out what kind of structure
that might or might not take, and how we would assure ourselves that we would
get done at some reasonable point. That is what I would like to do.
I’d like to go ahead and get started in order on the agenda again, so Mitch
Icenhower, if you can get started. Each of you can introduce your company or
who you are with or who you are representing, please.
MR. ICENHOWER: Thank you very much for the opportunity, I appreciate it.
Thank you to the folks from HIMSS who helped us facilitate our participation.
To jump right into it, I am Mitch Icenhower. I am the senior director of
Revenue Cycle and the Siemens Medical USA. I am also the general manager of
HDX, which is our EDI clearinghouse. We are in a unique position. I will be
answering both from the position of a billing vendor and as an EDI
Siemens provides HIT solutions for over 1200 provider customers dealing
with the health care administrative process. As HDX or EDI clearinghouse, we
have over 200 different payor organizations that we are working with, so we are
in a good position to see what is happening as far as readiness in the
Overall, our primary role when NPI rolled out was one of communication. We
did just like the payor organizations and everyone else did; we focused on
getting communication out to our customers, both payor and provider, through
all the normal methods, but then we quickly moved on to our next role, which is
to update the software.
For us, this is not a small thing. We are a relatively large provide. Our
primary customers are hospitals, health care organizations and large practices.
We support several systems. We have invested roughly 15,000 hours in preparing
our software and our clearinghouse operations, making them enabled to work with
What that means is the mechanical ability to support that, updating the
multiple patient accounting and patient management systems, updating databases
and the interfaces and input screens, so that the software is quote-unquote
ready. So when you ask us are we ready as vendors, we say yes, but no.
Why we would say no is the end result is, we have worked with our
providers, and to answer one of your questions, we estimate that over 90
percent of our providers have gotten their numbers.
MR. BLAIR: Ninety percent have gotten their NPIs?
MR. ICENHOWER: Yes. There are some nuances as to how they have enumerated
and how they have decided to do that. As the folks from HCA were stating
earlier, most of them to play it safe have followed what their legacy
enumerations were, but that wasn’t consistent from payor to payor all the time.
So even just playing it safe has still left some variables.
But even though those providers have their numbers, they still haven’t
communicated them to the providers. The payors haven’t necessarily built the
appropriate crosswalks, and the big gap that we see right now is testing. There
has been very, very little testing done between parties. So that has shown that
there is very little communication between the parties, and that there is
variance in the ways that the payors have elected to implement under NPI.
When we went through, we tried to develop — to give you an idea of the
vendors, yes, we have profitability, but we have a covered entity aspect too.
So we wanted to go through and make sure we were covered from a clearinghouse
perspective, have our operations in place. We also looked at it as a software
vendor and say what do we need to do.
We need to provide flexibility, because like you said, there is going to be
variance from payor to payor, so we tried to build flexibility in that. We put
a dual use switch in so that the providers can switch to the NPI and off the
NPI per payor, per testing, to be able to allow them to work with the multiple
testing and treating partners that they have. We have put together stuff that
makes it easier for them to set up their NPI information with us. All that is
just helping the provider customers that we have get ready for these pieces.
Where we get into the challenges, what is left to do? We have estimated
5,000 more hours of effort on our part, primarily continuing to monitor the
industry, collecting those NPIs and setting them up in our systems, determining
where the payors are and performing testing, and reacting to the issues that
Already we went into our payor organizations, we polled over 200 payor
organizations. At the time we did this last summer, we got a low response. Less
than 10 percent of the payors we were querying on NPI came back and had a full
response for us. It wasn’t that they didn’t want to answer; they were still
figuring out how to answer in a lot of cases.
What it has shown us is, as you look at the status of where payors are,
even though we got a small sampling back, we had a great amount of variance in
how things are being implemented. There isn’t a lot of consistency.
I will say this. I believe every payor organization that we are working
with thinks that they are implementing NPI the way that it is supposed to be
implemented. But there are a lot of inconsistencies in the payor organizations
as to how that is going to happen.
It goes back to the enumeration piece. If your legacy identifiers were not
consistent from payor to payor and everybody goes out and says I am going to
try to play it safe and stay close to my legacy pieces, then you have already
introduced an amount of variability. As vendors we are trying to support that
amount of variability, but when we get into testing we are going to uncover
lots and lots of issues.
We are testing some payors. We have uncovered issues as simple as, payors
are looking at not necessarily returning the same NPI on the 835 that was
submitted on the 837. They want to pull it out of a profile that the provider
had earlier selected. Technically this meets compliance because they are
returning the NPI, but it defeats the purpose, and it is certainly not in the
spirit of what we are trying to do.
We are working with payor organizations to raise issues, to bring them
together — I know that other organizations and clearinghouses are doing the
same thing — to try to get consistency on how we implement. Part of the
providers’ reluctance to release information and engage in the testing is that
certain vendors aren’t ready, but other ones are saying I have got several
directions coming from several payors, how am I going to react to that, how am
I going to prioritize my testing.
I would say that if I had to put an estimate on the amount of testing that
we have to do, we are probably less than ten percent of what we think the total
testing required for this is going to be. That is a lot of work to do by the
May 23 deadline. Quite bluntly, just based on the number of trading partners
that need to be testing end to end, making sure that their systems work
together and making sure that the providers’ reimbursement is not negatively
impacted, it seems unfeasible regardless of what effort we would take that we
would be able to hit a May 23 deadline.
MR. BLAIR: Just a quick question. How many payors do you support with the
MR. ICENHOWER: Across multiple services it is around 250. Those are mostly
major payors. We aren’t working with the smaller health plans that often. As a
hospital and health system clearinghouse, we are going to cover the top 90
percent of the volume of payors, so those smaller payors in the bottom ten
percent are probably at a readiness state that is significantly less than ones
we are working with.
I believe the payors absolutely are ready. The providers believe they are
ready, the software vendors believe they are ready to some extent. We are going
to get together and we are going to find out that there is a lot of
This isn’t anything that we didn’t learn in HIPAA, but right now there is
just the time it takes to test that is going to make a big difference to deal
with the issues that you have found.
For instance, in the testing we found that the 837s and the 835s don’t have
the data items. There are identifiers that are provided on the 837 that —
those fields don’t exist on the 835. What is happening now is that we are going
to have to as a vendor build systems to retain the claim data so that we can
map this stuff back, because if the NPI comes back and doesn’t identify the
provider at the same level of granularity that the 837 did, then we are going
to negate some of the providers’ ability to reconcile that payment and claim,
and those are very important features and functions that providers have
developed over the last couple of years, and we are going to end up doing extra
work. But we didn’t find a lot of these problems until we started testing.
It is very reasonable to assume as we go through testing, just like we did
with HIPAA, that we will identify issues that will make it more than just a
straight line testing effort. There will have to be a running period involved
Overall, the industry is taking varied approaches, the payors are taking
varied approaches even to how they build their crosswalks, even to how they are
going to treat the May 23 deadline, and even sometimes in the definition of
what dual use really means.
There needs to be more communication. There may be opportunities for
organizations that work with the payors, the organizations that represent them
as well as the clearinghouses that work with them, to try to get normalization.
We are recommending at this point, because of the lack of testing and the
potential risk to payor reimbursement, that we think that the WEDI
recommendation of 12 months from NPPES is probably a good time frame. However,
the trick is, what do you do with that time frame. You have to have some
A certain amount of it is just, we need to test, we need to shake it out,
we need to work together as an industry. But there are other concrete things
that I think WEDI has recommended in the past, and maybe a part of the proposal
that they are bringing forward, that I think should be considered.
We see the things that we need to do during that time period as, continue
to help providers access the NPI stuff, share it with the payors so that they
can build their crosswalks, improving the communication on the transition
strategies and testing.
There ia a varying level of how much testing support is available, based on
how that payor’s test system is. The more sophisticated payors have great
testing capabilities and abilities and environments, and the less sophisticated
payors don’t. But the provider has to go to NPI. They have to go across the
board. The more variance that they have, the harder that is to do.
We need to work to try to find ways to normalize that. We can do it as a
clearinghouse, we can work to normalize those pieces, but we think there are
organizations like WEDI and like CAQH who might be able to provide leadership
roles in the payor industry, and pulling together the information and dealing
with some of the key implementation issues.
Really, engaging in end to end testing — and when I say end to end, I
don’t mean the claim just goes through. It is all the way through to the
payment, how does an 837 go out, how does an 835 come back, and does that make
sense in the way those things react together.
If there are issues like we think there are with the 835, where we don’t
have enough data items, then we are going to have to work. It is too late for
5010, it is going to be in the current release. We are going to work with the
appropriate WEDI, X12, those organizations to get those data elements in. But
literally that could be years before that standard is mandated and adopted. So
in the meantime, we understand as a vendor we are going to be responsible for
work-arounds, for lack of a better phrase for it. Claims scrubber vendors will
probably be able to do this pretty easily, hospital and physician billing
vendors will have a little more work to do it, but it is something that we are
going to have to embrace.
We don’t think these are the only issues that we are going to find. We
think that the time that we spend here has to be some concrete efforts of both
education, normalization of implementation and a way to react and escalate the
issues that arise from end to end testing.
MR. REYNOLDS: Thank you, Mitch. Next is Catherine Schulten.
MS. SCHULTEN: Good morning. I would like to first introduce myself and let
you know what company I am here representing. My name is Catherine Schulten. I
work for a company called EDIfecs. I want to mention that because part of this
presentation is about vendors that are providing solutions to the NPI issue.
I want to state that EDIfecs is unique, in that we are not a vendor
specifically to providers or vendor specifically to health plans. We are a
vendor that provides tools that help facilitate both providers and plans.
Some of these tools that we provide are specific to EDI. They are things
like HIPAA transaction validation, trading partner onboarding. We are also a
CAQH course certifier, and we just happen to have an NPI compliance and
I am also here on behalf of HIMSS. I sit on the HIMSS AFECT advisory
council. I also serve on the HIMSS ambulatory business systems integration task
When I was asked to come here, there was a few key questions that I was
given in an e-mail that said, what is vendor NPI readiness, what NPI education
and outreach have been conducted today, and to provide an evaluation of
industry NPI readiness by May 2007.
I want to first define what is a vendor for purposes of this discussion,
and what do we mean by NPI readiness, and then to explain what some vendor
assisted NPI solutions exist.
When we talk about what is a HIT vendor, health IT vendor, in my mind there
are basically three groupings of health IT vendors. There are provider vendors,
there are payor vendors, and then there are vendors that provide tools. So
provider vendors are things like your practice management system, your billing
administrative systems, clinical applications, EHRs, these are all grouped in
the provider vendor category.
Then there are payor vendors. They make adjudication systems. Some of these
can be COTS solutions. Many of these are proprietary mainframe solutions. Quite
often they are a combination of all of the above.
Then there is this group called tools. These are companies that provide
solutions like translators, gateways, validation tools, application
integrations. These are applications that assist provider and payor vendors.
When we talk about vendor NPI readiness, what does that mean for each
group? The reason why I distribute these among the three groups is that quite
often when you talk about vendor NPI readiness, you are talking about provider
vendors. In fact WEDI in their survey pretty much focused on the provider
vendor readiness, not things like tool vendors or payor vendors.
What are some of the things that a provider vendor would say that he is NPI
ready? He is supporting the new data field for NPI. That might just be his
extent of what he is doing and saying he is NPI ready. But there is more to
that. There could also be developing the associative logic to combine the NPI
with the correct taxonomy code so that the health plan can go properly through
as required by the payor. Like I said, WEDI has done a pretty good job of
pulling together a readiness survey, and I’m sure that they are providing
testimony on that.
Payor vendors, the way they are solving, when they say they are NPI ready,
they are either doing one of two things. They are going to front end their
entire process with a crosswalk. That is the way most of the payors today are
going to be solving the NPI issue.
There is a couple of payors out there that I am aware of that are
remediating their entire system to support NPI natively, because they don’t see
that there is any future in continuing to enumerate every provider with a
legacy ID, which is what you have to do, if you are going to continue with the
NPI legacy crosswalk. Every new provider after May of 2007 still has to get a
legacy number. It is a secret number obviously, I don’t think they are going to
be telling the provider what that legacy number is, but that is the only way
the system works for them, is that they still have to do that crosswalk. There
are plans that don’t want to invest that type of money into continuing
supporting the legacy enumeration, so they will just remediate the entire
Then there are tool vendors. HIMSS has published a guide to vendor assisted
NPI solutions, and I included the website where you can find that link. This is
the document that defines the types of commercial off the shelf solutions,
tools that are available that address NPI.
As part of this document, we are also going to do a survey sometime in Q1.
This will be part two of that document. We are going to be surveying vendors to
see, of these different types of COTS solutions out there, what do you provide.
So we will have a nice document of vendors out there who are saying these are
the types of NPI solutions that I provide.
When a tools vendor says that they do NPI readiness, what does that mean?
There is about three basic things that that could mean. One is just NPI
compliance, which is some basic logic that tracks to make sure that the NPI is
properly formatted. It authenticates the check digit, that’s it, not much to
Then there is NPI validation. That is logic that queries an external
source, which would be the NPPES, to check the validity of the NPI. Then
finally, there are crosswalk solutions out there. There are simple crosswalk
solutions and then complex. Let me just define that real quickly.
Simple NPI crosswalk solution is something that uses deterministic logic.
It is based on a one to one correlation between an NPI and a legacy number. It
is not tolerant of any sort of variables in the way the NPI might appear, the
way the provider’s last name or first name or anything along that line. It has
to be exact, and then it can make the match.
Then there is this concept called probabilistic NPI crosswalking. This
replaces a simple lookup table with a flexible matching algorithm. It is
tolerant of variables, and it does not require one to one matching. So in this
situation you can have maybe different spellings of the provider’s last name,
but the algorithm is able to figure out, you said Smith Junior, but I
understand Smith can also be the right provider. It makes not really a guess,
but that is probably the best word to use, and determines the probability of
These are solutions that are available today for crosswalks.
Second, I want to give you some of what is going on out there in the
industry for education and outreach. Like I mentioned, HIMSS has developed and
published a guide to vendor assisted NPI solutions. Our phase two of that
document will be coming out later this quarter.
We are also discussing the idea of putting together an NPI fact sheet.
There is lots of documentation out there on NPIs. I think the industry has
probably flooded with NPI education. You can go to WEDI and read 27 papers on
every nuance of NPI, and you will find something out there that is going to
address your question. So I don’t think it is the lack of education. The only
reason why HIMSS is developing one is, they are trying to put together a simple
one-pager that we can give to a provider that would explain, this is the reason
why you may or may not need an NPI, who gets one and why do they get it.
The third question you had asked was an evaluation of the NPI readiness by
May of 2007. I personally am not an association, I do not do a formal survey, I
just asked a lot of doctors and a lot of health plans, what do you think.
These are some of the things I heard, so I just want to let you know what I
heard. Why are providers not getting their NPI. The biggest one, I don’t even
know about it, heard that many times. I heard from one provider that they said
someone else was going to file for it on their behalf. That is one that I
haven’t heard mentioned yet as to why people don’t have an NPI. Another one was
the belief they don’t need it because they file on paper. Then the final one I
heard was, oh, we have plenty of time to do it.
Some other things that I heard from providers was, no one other than my
affiliated hospital has asked me for it. The only person who has asked this one
doctor for his NPI was his hospital. He had never heard from a plan, he had
never heard from a clearinghouse, he had never heard from his vendor, give me
your NPI, just his hospital.
Another provider told me, my vendor hasn’t explained when or if they are
going to upgrade my practice management system to support NPI. He was assuming
that they were. I have heard rules are confusing, they’re not sure if they need
an NPI, they said I only file on paper, I don’t submit to Medicare. Many
expressed that they are worried that their payments are going to be different
as a result of using the NPI.
Providers said that they would be happy to share their NPI with anyone who
wanted it, especially in the case where they may be replacing their own social
security number on a health care claim. But once again, other than their
hospital, no one has asked me for it.
One provider specifically stated, in the past my local GMA chapter
published a referral UPIN booklet, and nothing seems to be replacing this; how
am I going to get referring provider NPIs.
Then I talked to some health plans and I got their impression of NPI
readiness. They said we are having problems getting the NPIs from the
providers. When they call providers, providers don’t know about it. If a
provider is already submitting a health care claim with an NPI, they say it
shows up in 15 different places within the 837.
They don’t know where to put the NPI. Or if they put the NPI, one day it is
one NPI and the other day it is another NPI. Who knows, it is just going to
show up. So the payors are having a hard time getting one NPI to show up in the
right place at the right time.
Providers are saying that they have an NPI but their practice management
system or clearinghouse doesn’t seem to be accommodating it. It is not making
it through to the health plan in the format that they thought it would.
This is what I am hearing from vendors. Vendors almost to 100 percent are
saying that their software currently accommodates NPI. However, testing is
limited. When they say they can accommodate NPI, they have a slot for it, the
NPI is in there, they unit tested it, works great, but there is no way to say
that this NPI in practice from providers, possibly through a third party and on
to payor, returning a properly paid 835 is actually going to work, because the
vendor is just testing as a unit testing. So we have a big gap here with not
having true end to end testing.
So in summary, I would just like to say that vendor and NPI readiness are
terms that you have to define within the scope of the discussions. If we just
say vendor, understand which vendor you are talking about, because different
ones have different ideas of what that means.
Also, very few providers and health plans have conducted NPI end to end
testing. They have done a lot of unit testing. I think one of the reasons for
this is that they don’t have test environments that mirror their production
data, so they find it very difficult to do this end to end testing. In fact,
they have to incorporate their live system for the testing, and it is not
something they want to do across their entire community.
Thank you very much, appreciate it, and I look forward to your questions.
MR. REYNOLDS: Next is Stacy Trease.
MS. TREASE: Good morning. My name is Stacy Trease, and I represent the IT
project management department within Gateway EDI, which is an electronic claims
clearinghouse. We are currently an industry leader that processes accurate and
timely health care transactions, and we have been in business since 1983. We
currently have 6,000 offices within our practice. We also serve over 3,000
payors, which comes to about 250 direct connections, and we also do provide
tools to help reduce the average overall error rate to seven percent, and do
7.5 million transactions monthly.
That is wonderful and all, but that doesn’t mean a whole lot if we are not
able to support the governmental mandates that are coming down our way, just
like all the providers and vendors that have testified thus far.
Before I get started, I just want to say a special thank you to HIMSS, the
Health Information Management and Systems Society, and the HIMSS AFECT advisory
council for facilitating my participation in today’s panel.
Today I will be discussing the Gateway EDI NPI readiness, our
implementation issues that are specific to our business, the industry wide
issues that we have been hearing from our clients as well as what we have been
observing while we have been testing as well, and the Gateway EDI education
outreach efforts that we have been doing.
We are currently accepting claims with dual identifiers, with both the
legacy and the NPI identifier. We are also accepting electronic remittance
advices with dual identifiers, and we are actively testing with trading
partners, with both inbound and outbound on both dual identifiers and NPI only
As Mitchell has stated, we have uncovered quite a few discrepancies with
payors as we have been testing. Each trading partner seems to have a different
way of implementing the NPI taxonomy code and different edits within their
system, similar to how the 837-P and 837-I has been implemented.
We are currently developing a solution for claims status and eligibility
transactions to support the NPI, but those are still in the development phase.
We have not begun testing those transactions.
The implementation issues that we have faced thus far, number one, have
been the varied payor implementation schedule. It seems that each payor that we
talk to has either a phased approach or a date in the future that they will be
implementing the NPI, or they are trying to implement the NPI but still in one
of the phases.
We have very large spreadsheets that seem to change on a daily basis as we
talk to each of our different trading partners. They may have planned with good
faith to start taking NPIs say January 1, but as we get closer, that date
shifts back. Or maybe they find that a second or third phased approach turns
into a fourth and fifth phased approach.
So as we are getting closer, I think that a lot of vendors, clearinghouses,
payors, providers are all running into the same type of issues, where like any
project that you run, the first 90 percent of programming or resources takes
the quickest amount of time, and the last ten percent takes the most amount of
The requirements for each of the trading partners also seems to vary. The
provider ID requirements, whether or not they are going to be ready for dual
identifiers or NPI only, or whether they will be requiring an NPI within
specific loops of the 837 transaction also are varying from payor to payor.
We are also finding that some of these different payors are requiring
re-enrollment, based upon the NPIs that are received and a combination of the
taxonomy code that they choose to use. Some of the payors that we talk to are
using this as an opportunity to recontract rates with their providers, based
upon these different taxonomy code or specialty code combinations. So that has
become an additional staff need for us as well.
We have also found that different payors are implementing crosswalks in a
different way, based upon their own needs. Some are going to populate their
crosswalks based upon the enrollment information we give them, some are going
to populate the crosswalks based upon the claims that come in their system and
it will auto populate. It seems to be across the board differences based on
each trading partner.
Taxonomy codes have also been a very large issue. Depending upon the payor
that you talk to, some will require one single taxonomy code for a provider any
time they submit a claim. Others are going to require a different toxicology
based upon the services that are provided on that claim. So at this point, the
provider or the clearinghouse, whoever submits that claim, is going to have to
have the ability to send multiple taxonomy codes based upon the codes that are
being submitted for specific providers.
Most of the vendors that we talked to thus far do not have the capability
within their system. Most are working on it, but this does seem to be a
The zip plus four is also something that many are concerned about. For
instance, say they have an older practice management system, and it only
supports the five-digit zip code. All of a sudden now we need a nine-digit zip
code. They are not able to provide that in a lot of cases.
What Gateway EDI is doing is trying to auto fill that four last digits for
them by doing a lookup in the zip code tables for the address that they are
submitting. But a lot of times they do not have any other choice, so we are
trying to do support tools in that manner.
Communication we have also found has been a big issue. There are a lot of
unannounced changes. Maybe the opposite of what I discussed before is
happening. Maybe they get to December 15, an they were hoping that they would
be able to accept NPIs as of January 1, but now they are ready December 15.
Maybe a newsletter goes out to their providers, but we as a trading partner do
not know. So we may find out last and all of a sudden be scrambling to make the
programming changes after the providers had say a two-week or 30-day window in
order to get this done.
We also are having difficulty finding an informed technical contact that we
can always depend on for the most updated information at our trading partners’
We are also finding that as we talk to different payors that after May 23,
some are going to be rejecting plans up front if the NPI is included, some are
going to not reject claims up front if the NPI is included, whether or not
there is an extension or a dual identifier period that is approved or what have
you. So we already know that not only will there be differences in
implementation prior to May 23, but afterwards as well.
One thing we found in speaking with our providers, and this is a very
common thing when we are on the phone with them, is that they really don’t
think this is going to happen. They have a common belief that NPI just won’t
stick. Maybe if enough providers don’t get it or enough people aren’t ready or
enough people don’t use it, that maybe it just won’t happen.
Obviously that is a very large concern. We try to increase our education
and outreach and talk to each of these providers and support them as much as we
can, but we currently only have 30 percent of our providers reporting an NPI.
We have been doing a very expensive request for the NPIs from these providers.
We also have been incurring additional staffing costs for the format
changes that are coming across trading partner testing, which is engulfing
quite a few resources, configuration changes, re-enrollment as we discussed,
clients without vendor support and education and outreach.
The clients without vendor support is a very important one. Whereas we may
have preferred vendors that we work with on a day by day basis, we also can’t
forget about those clients that have a vendor that may not have a preferred
relationship with us, or have such an outdated or antiquated system and can’t
afford the $30,000 upgrade, as someone mentioned earlier today.
Across the industry, I think that most people are saying pretty much the
same thing. We have got the application procrastination, although it is a lower
and lower percentage all the time. We still are seeing providers who just
aren’t ready and who don’t plan to apply for an NPI until later. They feel they
have plenty of time.
The enumeration subparts confusion still exists for people who feel that
someone else might be doing their NPI, or maybe they are on the phone with
payors and payors are saying you really need to have only one NPI with us. Or
maybe you should consider getting more than one NPI, one for each of your
taxonomy codes, and then you wouldn’t have to send us a taxonomy code in
addition to your one NPI, things of that nature.
The NPI dissemination; obviously not having all of these publicly know, it
becomes an issue for the referring provider segments, because a lot of those
providers don’t know exactly what to put in those segments, as Catherine had
We discussed differing payor requirements, differing payor implementation
schedules, the crosswalk implementation, enrollment and taxonomy codes
As far as Gateway EDI education and outreach, we have done 15 training
classes for our submitters during 2006. We have 18 training classes scheduled
for 2007 and more are being booked all the time. As these fill up, we do add
With vendor communications we have been doing early distribution of format
changes with conference calls, offering technical support wherever we can. We
are collecting and publicizing any of our NPI related survey results which we
have just recently added to our website. It is an anonymous poll that sites can
take to let us know whether or not they have received their NPI, whether or not
they plan to use their NPI, whether or not they have support from their
vendors, so that we can see where the areas are that we need to help reinforce
assistance with them.
We are distributing the Gateway EDI implementation plan to all of our
trading partners, if we have not done so already. We have been doing assorted
Gateway EDI sponsored web articles, usually on about a monthly basis for each
of our submitters. We are also including an NPI corner update within the
newsletter that goes out to all of our trading partners. We are adding
additional links onto our website. Currently we have links to the applications
of soft systems. WEDI articles are being linked with permission. We have got
the CMS website articles. We are also doing guest speaking at assorted
conferences, and we have an active presence within several health care
I think probably the biggest thing that we can do as organizations is to
work together at this point. I think that in the past, we all have our own
niche. We all have ways in which we have newer tools or better tools than one
another. I think probably the success at this point is to find a way for
clearinghouses to work together, for organizations to work together, for
vendors to work together with trading partners to make sure that the end to end
testing is able to be completed.
We currently have a lot of vendor coordination with testing with all of our
submitters. We do end to end testing within our system and can provide back to
those vendors what we would be sending out to the payor on their behalf after
it goes through all of our programming before they put any of their format
changes in production.
We also with the vendor or the submitter’s permission are working with
payors and requesting a mock adjudication cycle so that they can put it through
their system and return to us an 835. Unfortunately we are running into a lot
of the same kinds of things Mitchell discussed, where the 835 information is
not coming back with the same NPIs as were submitted, the unsolicited 277, same
type of situation. We are having a hard time with implementing this in
production, but we continue to do testing and will continue to do everything we
can to help the provider community.
MR. REYNOLDS: We have a change in the agenda. Robert Burleigh, we
appreciate your joining us, if you would introduce yourself, that would be
MR. BURLEIGH: I am Robert Burleigh. I am here on behalf of the Health Care
Billing and Management Association. HBMA is the nonprofit trade association
representing the medical billing industry. I am president of Brandywine Health
Care Services, which is my company. We are a consulting company, primarily
consulting to the billing industry. I am a past president of HBMA.
We had a long version of our testimony, we have a short version. We have
shortened the short version to respond to the questions that were asked
To summarize HBMA, we do the heavy lifting in the industry. About 650
companies who bill for tens of thousands of physicians across the United
States, and companies come in all sizes, some of them publicly traded. We
believe that our members submit something on the order of 15 to 20 million
claims a month or more on behalf of primarily physicians. So we have a lot of
HBMA has done a lot of work to educate our members and through the members
to their customers on NPI enrollment. Billing companies, besides submitting
claims, often provide other management services, and that includes provider
enrollment. So many of our member companies have handled the NPI process for
HBMA has worked very closely with CMS. Karen has left the room for a
moment, but we wanted to thank CMS for their outreach efforts in providing
speakers to our programs and so forth, because we think that has made a
considerable difference within our universe.
We have been doing this for more than three years. At a suggestion by one
of the CMS staff, someone who works for Karen, last December we conducted a
survey. In the handouts you have a copy of our survey results, and I will be
referring to those. We surveyed our membership for NPI readiness, much in
response to the questions that you have asked today.
135 of our 650 member companies responded. It is about a 20 percent result.
That is a little above what surveyors tell us is a reliable number. Billing
companies of all different sizes responded from the smallest to the largest.
We are pleased that we got the results that we did. More than 75 percent of
our members reported obtaining NPIs on behalf of their customers, and we will
get to a little more on that in a moment. Most of the people who have gotten
numbers are frustrated by the lack of numbers they have been able to obtain for
referring physicians, which is a secondary issue.
A number of questions have come up this morning about testing. I have some
information to report on the matter of testing of NPI. It is anecdotal at this
point, we don’t have enough to survey, but some of our members have reported
that in testing submissions with NPI numbers, a number of claims were rejected
because of discrepancies between the provider information on file with the
enumerator and the information that the provider put on their Medicare or other
payor enrollment forms, things as simple as with or without a middle initial.
So if there was a lack of consistency between them, the claim was rejected when
they tested the NPI submission.
In another case, the claim was rejected because the enumerator in their
data had a lower case suffix on the name. So Junior, Jr., was lower cased and
the payor had Junior but it was upper cased. The disparity between upper and
lower case caused the claim to reject. So while this is an early indication, it
is cause for great concern about the results that we will find in further
testing as time passes, and it is very consistent with what the other speakers
have mentioned in terms of variances by payor. I think this is the tip of yet
another iceberg that will reveal itself more fully in the next few months, and
is cause for great concern.
Questions about provider issues and why they haven’t enrolled. I think what
Catherine mentioned in her eight points is consistent with our own experience.
One of our board members was a lecturer at a conference recently, and brought
up the subject of NPI, and of the 30 physicians in the room, none of them knew
what an NPI was, had never heard of it.
It is our belief that a lot of the communication and outreach efforts have
been electronic, and we have information that many, many practices are not
online, do not use electronic communication, and as a result they are deaf to
the dialogue that has been going on to inform them of NPI. We have some
suggestions on that point as well.
MR. BLAIR: In terms of a point of clarification, the information you are
sharing with us right now is from a survey that you have taken in December, is
MR. BURLEIGH: Yes.
MR. BLAIR: Thank you.
MR. BURLEIGH: In fact, the survey includes mostly just yes, no or numeric
results. Where we asked for specific text responses, we have included all of
the responses that were provided in the text, which included in some cases the
reasons why providers didn’t have an NPI number, and they are completely
consistent with what the other speakers have mentioned.
Of major concern in the billing industry is the absence of a data
dissemination or directory of NPI numbers. A significant number of our members,
over 60 percent, bill for so-called hospital based physicians, radiologists,
pathologists, emergency physicians, anesthesiologists, doctors who nearly
always have to put a referring physician number on their claim. Without some
modification or adjustment in the rules as they are currently written, the
system will grind to a halt in significant numbers.
For example, we have had several companies report to us that in one case,
400 pathologists is their client base. If they were to acquire NPI numbers for
all the referring physicians referring patients to their customers, it would be
on the order of 50,000 referring physician numbers. Their answer to us was, if
we had a directory available today, we are not sure we could make it by May 23
in order to load that information. If there was an electronic format available,
that is possible. So when you get into large numbers, some of these things
become pretty frightening.
We have 60 percent of the billing company responses to our survey. They are
going to need NPI numbers from more than 200 physicians each. Again, that is
representing 650 companies, so as you can imagine, these large numbers are
going to be a real problem for the billing industry. Fifty percent report that
they have not received NPIs for any of the referring physicians and so forth.
Our recommendations would be to make sure that there is a directory, that
it be available soon, and if it isn’t going to be available soon, that there be
a default mechanism of some kind for that particular issue.
In terms of the whole NPI process, a so-called primary NPI number, that
would be the NPI number for the physician seeking payment, as opposed to a
secondary NPI number, which is the number of a referring or ordering physician.
So if a change is made that requires an NPI number for the primary submitter,
the doctor seeking payment versus having an NPI number for the referral source,
that would be a half step solution. If that was deferred for — I think someone
mentioned 12 months or so, we believe that that would be an effective way to
diminish some of the damage that will occur otherwise.
Some kind of a public use file. Assuming that we have accurate and
accessible NPI numbers, we still think that the deferral for the remainder of
’07 or 12 months as has been suggested would be worthwhile.
We have been in communication with WEDI. We know their recommendations and
we support all of their recommendations. We have been a member of that choir
for about two years in making those suggestions.
We have a number of other things when we get to questions to suggest.
MR. REYNOLDS: Thank you. Let me make one or two comments first, and then
Jeff is on the list, and then I’ll start making the rest of the list.
When we get to the end, just like I did in the last panel, I’m going to ask
my last question a little differently, my last, last question. Last time it was
whether providers should have their numbers by May 23. The next two portions of
that are whether clearinghouses who are covered entities ought to be able to
test by May 23, and whether or not payors ought to be able to test by May 23.
We have all talked as a committee about the lack of our ability to get to
everyone, because not everyone is a covered entity. But those are three sets of
covered entities, so i didn’t want to change that question on the fly. While
you are answering other questions along the way, if you will think about that.
Our charge is to discuss with the Secretary whether or not there are really
major impediments to the three of them getting to that point by May 23.
Obviously each of them arriving at May 23 doesn’t necessarily make us implement
One quick question I have for you, and I’d like you to nod your head. I
would think that if you just replaced NPI on all these slides with the HIPAA
transactions, 5010, ICD-10, claims attachments, you have got a pretty good
presentation that is going to work with us for years.
I think what is important about that is, this is the first time we have had
this clearly laid out from the vendor position to us. I just think as we are
deliberating our whole process, this presentation works; you just go out and
change a few words, but it works all the way along the way. So I just wanted to
make sure I had at least captured that in my own mind.
I think you have done an excellent job laying out from the vendor
standpoint. We have always looked a lot at the covered entities and we never
had a chance to what I see as a complete solid picture and structured picture
of what you guys are going through, so I comment you for that.
With that, I will turn it over to Jeffrey.
MR. BLAIR: Harry, I could defer my questions. I think we need clear answers
for Denise to compile the answers to our four questions. Did you want to
separately very quickly get the answers to our four questions first, and then
I’ll save my questions for after?
MR. REYNOLDS: Yes, I think we could do that. Let me let Mike ask a question
first. I am going to change the questions in this group. Denise and I are
taking copious notes. I think you have given us what are the reasons, but I
would really like to focus on number four. What is the structure of this — if
we were to change this May date, how do we make it happen.
DR. FITZMAURICE: I am puzzled, maybe a little bit bothered. We talked about
the 837 and the 835 today. Tomorrow we will be talking about claims
attachments. Soon we will be talking about quality measures, computation and
reporting, physicians have to submit quality information to get a 1.5 bonus in
the coming year. I see a lot of this flowing through vendor systems and through
clearinghouses. Then we are going to get to pay for performance. So this data
becomes real in the adjudicating claims.
We are talking about a Nationwide Health Information Network, and we are
talking about practice vendor systems that will facilitate all this in
clearinghouses. As you look further down the road, clearinghouses could be the
entities providing the pipelines and translation or mapping services for the
NHIN, the Nationwide Health Information Network. It is one possibility. Clearly
clinical information would be needed to be routed to providers, and the NPI
would be a critical part of this routing and authentication process. You have
got a private pipeline already. So while I haven’t heard much discussion about
clearinghouses and vendor systems being linked with the NHIN, it seems to be a
natural issue three, four, five years down the road. But the discussion about
the lack of a laboratory, lack of a test environment for end to end testing
means that the flexibility of a system to adopt to this and to provide new
services is called into question. It may not be too early to be thinking about
Do you have any suggestions for improving the flexibility? An NPI it seems
to me has increased the field width, and you have got it knocked if you are a
provider system. There may be some logic behind it, and you have got to link it
with a taxonomy code. It is probably more complicated than I am saying.
MR. REYNOLDS: Mike, in this audience you could get hurt doing that.
DR. FITZMAURICE: I don’t mind being hurt if it moves it along. Do you have
any suggestions of recommendations that we could make or things that we could
look at that would increase the flexibility of the industry to deal with the
HIPAA transactions and the other things that are coming down the road?
MS. SCHULTEN: I’ll start at this end and then we’ll just go on down.
There are things out there that can certainly help facilitate the testing.
Obviously large health plans — I shouldn’t say that. There are some large
health plans that have testing environments. I was surprised at things that I
thought would have a testing environment do not. There are hospitals that have
a test environment.
These organizations are able to accommodate this end to end testing, but
then you get down to organizations that are much smaller, that can’t afford to
have some sort of duplicate environment running simultaneously that mimics
exactly their real life data.
There are tool vendors that can provide this type of solution, so they
don’t have to double up on their investment in a test environment. They can use
a third party to help facilitate testing. I would like to see payors and
providers look out there for commercially available testing solutions that
could help them with their end to end testing. I think that there has been not
a lot of need to do it up to now.
NPI, claims attachments, 5010, ICD-10, you name it, for the rest of our
lives until we all die there is going to be a need to have this test
environment. You need to invest in this now. It is never going to end. It is
going to continue on.
MS. TREASE: I think there are four different things we could do, and
probably more, but just off the top of my head, I think that if we do make any
changes in the future, if we do start to make — of course there are many
changes, you listed quite a few. Maybe if we included a definition of testing
requirements within the rule, that might help everyone to think about what they
need to have within their system in order to test efficiently. I’m not sure if
that is a possible thing to do, but it might be something to think about.
Perhaps an HIN could partner with tool vendors or clearinghouses, similar
in the way that Fox systems in CMS did, where maybe one person or a combination
of vendors or clearinghouses or what have you could provide a solution that
anyone could use free of charge, for instance.
If you wanted an enumeration today or you needed assistance with an
enumeration, you could call Fox systems and they will help you; they are
contractors with CMS. Maybe this would be an opportunity for maybe a small
vendor to grow.
Also, I think that it would be helpful if the TCF variations that are
currently out there with different trading partners were addressed and nailed
down a bit, so that as we bring on more types of changes within the transaction
that we already have a handle on the basic 837s, 835s and things of that
MR. REYNOLDS: For everybody’s understanding, that is transactions to code
MS. TREASE: That’s right.
MR. REYNOLDS: Thank you.
MR. ICENHOWER: I’d echo a couple of things. There are definitely different
constituencies here that what we always see. There are the provides, vendors,
the payors, the payors vendors and the clearinghouse. If you go through it,
each one of those — Catherine really spelled out and did a great job of
explaining each one of those pieces. There are strengths and weaknesses of each
one of the vendors in each one of these areas, the sophistication and size, why
can’t we test at every payor. A lot of it has to do with the size and
sophistication of the payor because of their IT environment. Generally it is
going to map to the size of their organization. That is just a fact. The larger
ones are more ready to handle some of those things.
But if I could say the concrete things that I see that help us, there
really has been a lot of information out on NPI, but not a lot of
intra-organizational communication. If you compare it to what we did for HIPAA,
we really haven’t done as much communication of what specific payors are doing,
what providers are doing.
A lot of the SNP initiatives that we get under WEDI and those kind of
things were very helpful. It wasn’t just about, here is education on how this
process works; there was a lot of cross-organizational communication. While I
see that payors have put out in a lot of different fashions, we seem to be
missing the connection between the organizations, and that has hurt us a lot.
The test environments are a key component, and being able to do that. As I
said, it is related to size, it is related to investment. For the most part,
either you can buy a tool in the middle, or vendors are willing — most of us
have cost options for full test environments. It is just an additional
investment that folks need to make. The real key is synchronizing with data
that is going to process like production data between all these different
entities that we talked about here.
So it would seem to be some kind of test bed or sampling of test data that
you use that would be something that would be very helpful.
I happen to work with one of the HIPAA followup efforts that NCQH has
sponsored, which is the core initiative for ticket eligibility. We have defined
the standard, but we really aren’t getting the benefits as an industry. What we
have done is try to focus on developing operating rules on top of that.
In phase one, one of the first things we came to was the need for
standardized testing procedures and a standard test bed of data that we could
interchange between the partners so that we could try to synchronize these
different test and production systems and have some way of saying, I know what
the result is going to be. Those are the kind of initiatives that are going to
If we take a look at what we did with HIPAA and what we are not doing now,
what we are doing is followup efforts to go through initiatives like core and
what we are doing in those, you will probably find that we are addressing the
same kind of problems that were described here. The vendors alone are always
going to stand up and say, I don’t have enough of a solution because I am only
coming at it from my constituency. I am providing the providers and the
There is a trizetto that is working with large payor organizations that are
doing that piece. They need to be pulled into an effort and make sure that we
are using some consistency. We have solved this problem before. We probably can
use a lot of the same tools.
MR. BURLEIGH: I think first, in reference to the NHIN, it is important to
realize that we are living in and have since the electronic age began in health
care living in a reactive driven infrastructure. The infrastructure wasn’t
designed and built. It has been cobbled together piece by piece, driven by
things that everybody reacts to.
We just change the 1500 claim form. It got dealt with. So there isn’t a
divine design that everybody can template their products and services to. We
have hundreds and hundreds of vendors, and many of them are unique because they
build a product for an individual medical specialty, or they have built it for
an individual or size setting, a target market, so to speak.
I keep track of EHR. I have a list of over 350 vendor companies, and some
of them are weeks old, some of them are years old. They come in all sizes,
shapes, flavors, and many of them are deigned for either a style of practice or
a specialty. You layer into that the cost and affordability of those products.
The smallest organization I work with right now are two nurse practitioners
working solo, no physician. They are looking for an EMR that they can afford,
and they can barely afford a laptop computer.
So when you try to imagine a system, a network if you will that can service
medical schools and faculty practice plans and solo physicians and all be able
to do most of the same things in the same way, that is why we have the problems
that we have.
I think very important to this committee, right at the intersection, the
crossroads, is money. We are here today because this is how doctors get paid,
this is how hospitals get paid and providers get their money. If this process
fails May 23 and they don’t get paid, it gets ugly in lots and lots of ways.
So I think that is an important context to put everything in. The idea of
some kind of a safe laboratory that everybody can utilize and can afford to
utilize is a great idea, but that cost again is a problem.
DR. WARREN: First, Robert, I just want to thank you for giving a nurse
practitioner example. I had to say that.
The question that I keep hearing, and I thought about it on the first
panel, is, everyone is requesting a 12-month extension. So I know in my own
projects that I run, you would like extensions, but I also know that as soon as
I get one, I quit paying attention to it until we get close to the deadline
So what kind of assurances do we have that work will continue at the same
pace if an extension is granted?
MS. SCHULTEN: Personally, what I would like to see if we are going to have
a 12-month extension and we were all going to be doing our homework diligently
this time, is a certification process included in this for the next year.
Just like with Core, my company is a certifying testing entity for Core,
people can do 270s, 271s right now because they somehow manage to get through
to the back end system and responses come back out. Just as we could do this
with NPIs, you could test with a neutral third party, that my transaction with
an NPI managed to get through and it looks like it is properly formatted, it
has been validated as a proper NPI, which means we would have to have some
access to the NPPES database to insure that.
Now, there are business issues on top of that. There are health plans that
will want to say yes, the NPI is right, but with that taxonomy, you are only
going to get paid a buck-fifty for that instead of 30 bucks. So it would be
challenging — it could be done, but it would be challenging to also layer on
top of that the business requirements that have to go along with NPI usage. But
just as a baseline, you could say this provider can in fact send a properly
formatted claim with an NPI. It is a validated NPI, we know it is going to
Now, they will still have to test with their various payors to insure that
the payment is going to be right, but that is what I would like to see happen.
That is not difficult to set up, just that layer of certification.
MS. TREASE: I think that idea has a lot of merit. I think that however we
may run into a lot of the same types of issues. If we have a certification
process, people could still wait until the 11th hour to do their
certifications, although I do think it is a very good idea to make sure that
the state of the industry is exactly where we think it is, if everyone has to
go to one neutral third party vendor to check in and make sure we are all on
the right track.
Another solution might be to put in place a system of checks and balances
along the way. Instead of giving just a 12 month extension, maybe define it a
little bit lower down, so this is where we need to be at six months, this is
where we need to be at nine months, kind of a phased approach like a lot of our
trading partners are taking, for instance.
But it isn’t good enough if we are just going to suggest those things. We
have to have a way to enforce that, so that we have clear expectations and
clear consequences if those things aren’t met. We would also have to put a
tracking mechanism in place and a level of consequence.
MR. ICENHOWER: I think the fear of that extension is very real. That is
normal behavior. Not to be derogatory to my provider customers, they have got a
lot of things on their plate, and when the deadline is off, it is off.
But it is also important to recognize that there is an implicit deadline
behind the government one. A lot of payors were saying if this deadline holds,
I’m going to implement. If you are not ready, you are going to suffer the
problems at that point.
I think that is plenty of motivation on the provider side for folks to get
moving even with the 12 month extension. I don’t think most of the providers
that we are talking about here understand how hard a lot of the payors would
take that rule. I think if we get communication from the payors about not only
the extension, the time frame, what the capability and what the cutoffs are, it
is going to be as important a deadline as anything that we would put into the
law. It is the reimbursement that is going to be there.
The challenge we have got is that I really do believe that a lot of payor
organizations are moving ahead, are investing and are trying to do these
things. It is, are we leading the providers in multiple directions at once. So
the catch is, we can put that hard deadline at 12 months and if that is a firm
line and we communicate that, it will motivate the providers. But if we are
pushing into multiple or confusing or duplicate efforts between the different
payor organizations, then even with some motivated provider base, we may not
So I think the deadline of reimbursement is not to put some teeth into it
if we communicate it, but we have got to find a way to provide some kind of
MR. BURLEIGH: We have been supportive of an extension. I think that is the
most practical and perhaps the most predictable solution.
I think one of the important things to observe is that today there are 120
days from the day when this is supposed to happen, the night of, and we don’t
have very much conversation in this panel about the amount of testing that is
already happening. To imagine that in the next 120 days, people will begin to
test and successfully solve all the problems that will bubble up, some of which
I mentioned earlier, is a lot to expect, even if everybody already had an NPI
number, and they don’t.
The fact that we don’t even know how many don’t have it or have never heard
of it is another concern. So I think in terms of finding a practical solution,
an extension is a practical solution if the committee is trying to come up with
some other realistic approaches. If we wanted to take the most Draconian, it
would be to allow the NPI requirement to be what we would call a hard stop May
24, that if you don’t have a primary NPI number you won’t get paid until you
get one. The consequence of that could be, the enumeration will drown in the
number of requests for numbers and the system will get perverse again.
If you wanted to take a half step, it might be that those without an NPI
number will get paid, but their payment will be delayed — if they are
submitting a legacy number their payment will get delayed by two weeks or 30
days or something. That should motivate them to act, but once again it puts
enormous pressure on the enumeration.
So I think there are some other ways to tackle the problem, but the fact
that we don’t have a lot of testing going on yet, we are unsure how the payors
are going to react. They are not getting submissions. So I think the whole
system delayed a lot longer than we had hoped. But I think that would be
another way to deal with it.
MR. REYNOLDS: As a point of order, I’d like to make one comment. When I
introduced myself, I said I had no conflicts of interest, and I still don’t
believe I do. But CAQH Core has been mentioned a couple of times, and I am
national chair of that. However, I can clearly state here from a conflict of
interest standpoint, it is neither an NPI project nor an NPI solution. So I
feel comfortable continuing in my position as the co-chair here without any of
that, but I felt that is a responsibility I have, to at least make sure that
everybody who doesn’t know that, knows that.
Jeffrey, did you have any last comments? We are about two minutes from
MR. BLAIR: Kathleen, maybe you could help us a little bit.
MS. SCHULTEN: I will do my best.
MR. BLAIR: One of the comments that you made was that some of the people
indicated that they didn’t feel like an NPI was really going to come about. It
may be helpful for us to understand why some people feel that it won’t. Are you
able to help us with that?
MS. SCHULTEN: I think one of the reasons why people think an NPI isn’t
going to come about in the near future is because they have a — we as an
industry have a history of believing that an extension will happen, so there is
this belief that there will be an extension, so that doesn’t put the pressure
on them to secure an NPI today.
I think that is just the way we believe as an industry. If a rule comes out
we all fuss with it for awhile, we have testimony, we have WEDI white papers,
we ask for extensions, we get extensions, and then we probably knuckle down and
do our work. That is just my gut feeling about how this works.
MR. BLAIR: Thank you.
MS. TRUDEL: What do we do about that?
MS. SCHULTEN: Don’t give extensions.
MR. REYNOLDS: Karen, one of the reasons I have continued to drive my last
question, May 23 providers ought to be able to have a number, payors ought to
be able to test and clearinghouses ought to be able to test. That is what I am
trying to build as a discussion. The committee decides this.
That is what I am trying to drive towards. There is a difference between
blinking and closing your eyes. I think the last time we blinked. This time,
people may say that everybody is closing their eyes.
I liked your comments. I wrote down here that the general belief is, it is
a regulation date plus extension is when you should get worked. That is now
what the regulation says, that is not what the Secretary has put out, and that
is not what we are doing. So I think is why we are asking these difficult
questions as we go along.
MR. BLAIR: I also may add something. If we defer this time for the NPI, it
is going to confirm in an awful lot of peoples’ mind that if leading up to a
deadline, there is a lot of surveys showing people aren’t ready, that it is
only going to encourage and promote another delay.
MR. REYNOLDS: Simon, did you have a comment?
DR. COHN: It was just a clarification. We will talk more about that this
afternoon, but I just want to remind everybody, because there have been a lot
of conversations about delay throughout this particular session, I just want to
remind everyone, going back to the 837, to my understanding neither HHS nor CMS
has the authority to delay an implementation.
If you remember back last time, this was Congressionally done as part of
overall compliance activities. CMS and others had the ability to do contingency
plans, how exactly the implementation occurs, but delay is probably not part of
So I think we need to be aware of that.
MR. REYNOLDS: That is a good point. With that, we will break for lunch. We
are due back at 1:15.
(The meeting recessed for lunch at 12:20 p.m., to reconvene at 1:20 p.m.)
A F T E R N
O O N S E S S I
O N (1:20 p.m.)
Agenda Item: Panel III – Pharmacy
MR. REYNOLDS: We have a quorum, so we will begin. Welcome to panel three.
You should be well versed in this exercise by now, so you have no excuses for
giving really good answers. This is all about helping us.
This afternoon’s panel is on pharmacy. We are used to hearing from the
pharmacy industry on a regular basis in e-prescribing, so we are happy to have
you back on NPI.
We are going to go right down the list again, so we will go with Michele
MR. BLAIR: Did you want to review with them the primary questions?
MR. REYNOLDS: They have all been here, and I believe they are sick of the
questions, so they know what they are supposed to do, and I think we will give
them that opportunity. We will re-sequence them if they want to.
MS. VILARET: Thank you. I am Michele Vilaret, and I am the Director of
Telecommunications Standards for the National Association of Chain Drug Stores.
NACDS represents the nation’s leading retail chains, pharmacies and suppliers.
Chain practice pharmacies operate more than 37,000 pharmacies, employ 114,000
pharmacists, sell more than $2.3 billion prescriptions yearly and have annual
sales of nearly $700 billion.
These are the issues I am going to cover today. From the chain pharmacy
perspective, the enumeration of pharmacies does not cause a serious concern.
Most chain pharmacies already have the NPI numbers. As the numbers show, only
small chains who could have enumerated on their own are not accounted for at
For all practical purposes, we believe that all major chain pharmacies are
enumerated and ready to send their NPI numbers in a pharmacy transaction. One
chain that I spoke with is currently rolling out their software and will be
ready by April 1 to transmit the NPI in an NCPDP transaction.
There is however concern with the readiness of processors in regards to
having the pharmacy NPI files loaded in time for implementation, since they
must code to the new file layout, depending on how they are obtaining the NPI.
Many processors obtain files from NCPDP. Others require paper or online
registration from each pharmacy provider. It is impossible for pharmacy
providers to insure that all processors have all pharmacy providers loaded, so
that is a concern.
There is also confusion with taxonomy codes, since pharmacy and DME
provider numbers are linked to the same NPI, but use different taxonomy codes.
Some Medicaid agencies are not accepting the NPI registration of the pharmacy
if the pharmacy did not register with both taxonomy codes.
We are also waiting for an answer from CMS if the corporate ID is needed
for the 835. If so, chains will need to obtain a corporate NPI. So that is the
number that pharmacies may still need to obtain.
Prescriber IDs. The resounding concern that I have heard throughout the
industry has to deal with the prescriber ID. Chain pharmacies are very
concerned with how they are going to obtain the prescriber NPI number. It is
not feasible for pharmacy employers to call the prescriber and to ask for an
NPI, since we cannot be assured that we would get the correct number. We might
get the group practice number or the individual’s ID. This is especially a
concern with the fact that at this time, it seems that there is approximately
50 percent of the actual practitioners enumerated.
Also, NPIs on the prescription blanks are not practical, because that would
mean that the individual pharmacies would need to enter the NPIs into their
We need a standardized file from a valid source such as CMS. Pharmacy is
held accountable by third party plans, especially state Medicaid programs, for
submitting the correct prescriber identification number. If pharmacies submit
an invalid ID, claims can be recouped. The fact that the prescriber gave the
pharmacy an invalid number will not keep a third party plan from recouping a
claim. Thus, we need time to obtain a valid file in a format that we can use
from a central source, preferably CMS or NPPES, and be able to enter this
information into our system. If not, then the NPI requirement for prescribers
should not be implemented until this can be done.
Plans should share valid prescriber files with network providers in the
meantime. This includes state Medicaid plans. This would make the prescriber
NPI available to pharmacies so that they could submit claims until they can
obtain a file from a central source. Moreover, we are also concerned that not
all prescribers will have an ID, since the NPI is not mandated if you do not
directly electronically bill. Many prescribers do not directly electronically
bill, and may not see a need to apply for an NPI. This is especially true with
nurse practitioners and residents, and we look at these particular types of
practitioners as a problem.
We need to plan to insure that all prescribers apply for an NPI. It should
be noted that NACDS has made several attempts to contact AMA in order to avoid
prescription disruption on May 23. We have been unsuccessful at this time, but
we are continuing to try to get hold of them in order to work a solution out.
These are the concerns that we hope will be answered in the dissemination
guidance from CMS. We need this guidance from CMS as soon as possible. I cannot
emphasize that enough.
Readiness. You have asked this question several times today. Testing.
Approximately 75 percent of the chain members that I surveyed already tested
submitting claims with plans or processors. The other 25 percent plan to test
by March. However, no NACDS members are currently submitting claims, since they
do not have a reliable source for prescriber NPI.
Remember, when they tested, they tested using just the pharmacy NPI,
because they cannot submit a prescriber NPI.
Probably the most difficult function to implement in claims processing is
the reversal process. Fifty percent of the NACDS members surveyed indicated
that it could handle reversals at this time. Some may not be able to reverse
claims until the beginning of May, but still in time for them to make the May
As far as processing goes, pharmacies process almost four billion claims
online annually, and a smooth rollout of the NPI is imperative. Delays in
service due to a lack of information is unacceptable. Pharmacies don’t have the
manpower to make phone calls on every claim in order to obtain an NPI on the
prescriber. We ask that the NPI be rolled out gradually, no hard cut over
dates. That is especially true with state Medicaid programs. Allow plans an
option to adjudicate claims using the legacy number such as DEA, state license
number or the NPI number. Run a soft edit as a reminder for pharmacies to enter
the NPI if they submit the claim using the legacy number. Return the NPI number
in the message field when a legacy number was submitted and an NPI number is on
file with the processor. Monitor the integrity of the data during this period,
and as the data improves and more prescribers have an NPI, then put hard edits
into place and require the NPI
We request that you work with AHIP to activate major plans at different
times so that pharmacies are not overwhelmed. NACDS pledges to do the same.
As far as the implementation date, with all the work that remains to be
done, and the fact that we are still waiting for the dissemination guidance
from CMS, we are seriously concerned that the May 23 2007 implementation date
is not feasible. Pharmacies still don’t have the payor sheets. Pharmacies still
need time to program their systems. This is because we are still waiting for
guidance from CMS.
We need to understand how the prescriber ID will be disseminated and what
the files will look like. Without this information we cannot begin to program
our systems. All of this takes time. Pharmacies estimate that it could take up
to 180 days to cull their systems. Yet we have plans that are implementing the
NPI prior to the compliance date with a hard cut over. An example of this is
Pharmacies may not be able to service the customers. This is a real
concern. We don’t want to impact consumers. Time is of the essence, and we need
your help in getting the dissemination guidance out and helping us to obtain
prescriber files. We need time to add these files to our systems and to
maintain the integrity of the data once it has been added.
NACDS would suggest a one year extension to the compliance date over which
plans could implement the prescriber NPI. We recommend that plans accept both
the prescriber NPI and legacy numbers for the prescriber identifier during this
time to avoid severe service disruption to consumers.
MR. REYNOLDS: I need one point of clarification. When you said that a
significant number of your members are testing, then you said you had to
reprogram your system, is that just putting in the prescriber numbers? It is
not redoing your systems, it is just filling in —
MS. VILARET: That is strictly for adding the files with the prescriber
MR. REYNOLDS: Okay, I just wanted to be able to reconcile those two things.
MS. VILARET: The systems are already programmed. It is just in order to add
MR. REYNOLDS: Kathryn.
MS. KUHN: Thank you for having me here today and allowing me to provide
testimony on the perspective of NPI readiness from the community prescriber
My name is Kathryn Kuhn, and I am Senior Vice President of Pharmacy
Programs for the National Community Pharmacists Association. Just by way of
background, this is who we represent. Independents dispense 1.5 billion
prescriptions annually, which represents 42 percent of all retail
prescriptions. This totals $85 billion in annual revenues as of 2005.
Prescription medicines are a business, it is our primary business; 92
percent of annual sales in the independent pharmacy are from prescription
medications. The average number of prescriptions per pharmacy each year is over
61,000 prescriptions annually, which works out to 196 per day on average. That
was a three percent increase over 2004.
There are currently 24,500 single store independent pharmacies in the U.S.
This represents independent chains, independent franchises, independent long
term care, compounding specialty and home IV pharmacies and independent
pharmacist owned supermarket pharmacies.
These total sites represent 42 percent also of the nation’s 58,665 retail
direct stores. What we mean by retail direct stores are independent,
traditional chains, supermarket and the mass merchandisers like Target and
Walmart, for example.
The problems I wanted to start with in terms of what we are seeing with NPI
from the independent pharmacy perspective is first, enumerations. Historically,
the pharmacy provider IDs have been maintained by NCPDP in a central database.
That is the NCPDP ID. Of course, the NPI will now replace the NCPDP ID, which
was previously pharmacies’ legacy ID.
NCPDP was certified by CMS as an EFIO or bulk enumerator in May of 2006.
For the purpose of collecting and submitting records to the CMS, enumerator for
pharmacy NPIs on behalf of pharmacies with their authorization. But to date,
only 31 percent of the 35,406 non-chain pharmacies in the NCPDP ID database
have applied for NPI through NCPDP, or provided an NPI to NCPDP. So this means
there are 24,430 non-chain pharmacies missing from the NCPDP database that are
unaccounted for. This is based on current NCPDP data.
We really don’t know why this is a problem, despite NCPA’s continued
educational efforts, which I will talk about in a minute. Perhaps it is that
they enumerated pharmacies that directly applied with CMS may not have sent
their NPIs to NCPDP because they don’t understand the benefits. The NCPDP
database contains data not maintained by CMS, such as data that exists with
crosswalks to the pharmacy NPIs to the legacy NCPDP IDs. Also, things like
pharmacy network affiliations. Those are just two examples.
Health plans and PBMs can then use this NCPDP database to associate
pharmacies’ NPI with the legacy ID previously assigned to them in the plans’
processing systems. This will help insure payment to the correct pharmacy, it
connects the pharmacy with historical data, avoids potential claims disruption
and claims submission or errors in claims, payment back to the lack of
recognition of pharmacy NPI, and the claims processor database. It also avoids
the potential for numerous phone calls from health plans and PBM and claims
processors requesting pharmacy NPIs from the pharmacies, should that happen.
The NCPDP enumeration process however is not without its own set of
problems. The NCPDP enumeration application process involves a manual review of
each application and a six day turnaround gap after the pharmacy files are sent
from NCPDP to the CMS enumerator.
There are problems encountered through the NPI application process. Some
typical problems that are being reported back to us are things like the
pharmacist NPI instead of the pharmacy NPI is being submitted on the
application or provided to NCPDP, or the health care provider taxonomy codes
are provided instead of the NPI. So this delays the application process even
In anticipation of the large volume of NPI applications and NCPDP staffing
limitations due to constraints, and then the application processing challenges,
NCPDP is telling us that they can only guarantee that a pharmacy will be
included in their NCPDP NPI database if the pharmacy sends their application to
NCPDP or the NPI before February 15. This is because it is the goal of NCPDP to
make their database available to health plans and PBMS by May 1.
So if you look at the calendar, February 15 is only two and a half weeks
away, so it is unrealistic to think that these 24,000-plus pharmacies are going
to be populated in the NCPDP database.
Another question we have, and I’m sure others are asking this too, is what
if at the last minute NPI applications pour into the CMS enumerator, is the CMS
enumerator going to be prepared to handle a large volume of applications at the
Other general confusion among our membership about the NPI enumeration
process is due to the multiple NPI application processes available to them that
were created for pharmacies; should they apply through the CMS enumerator or
should they apply directly to NCPDP. So there has been a lot of confusion about
There is also a lot of confusion which we are continuing to hear throughout
the day here about the NPI application itself. For our members, they are
confused about which NPI type do I apply as a replacement for my NCPDP ID, is
it the type one individual or the type two entity NPI. Of course, the answer to
that is the type two NPI, but they are getting it wrong over and over again.
Another question that we have been getting a lot is, when do I obtain
multiple NPIs. There is also the Section 3D on the NPI application regarding
the provider taxonomy codes. There are currently seven options for community
pharmacies, depending on the type of services they provide, that determines the
category of the pharmacy on the NPI applications. There is a lot of confusion
about that. Throughout the process, from the time the NPI application was first
released, up until this point, in between there the NUCC made changes to those
health care taxonomy pharmacy categories, so that has created even more
Lastly, these provider taxonomy codes, because they list classifications of
pharmacies, our members are confused about whether or not this replaces the
need for another NPI.
So despite all of the non-chain pharmacies missing in the NCPDP database,
NCPA has been conducting quite a bit of significant education and outreach. For
example, we have co-developed with NCPDP last year a comprehensive list of FAQs
on NPI, and this does reside on both the NCPDP and NCPA websites. These FAQs
have been frequently highlighted and in our e-newsletter which is distributed
weekly, and we have a hyperlink to the NPI FAQs on both websites. Most recently
as yesterday, we also distributed another e-news weekly that contained a news
item on NPI application deadline.
One of our communication editors linked that news item to a page on the CMS
website, which I would like to share with you. It says here, for example, only
119 days remain until the NPI compliance date, do you have your NPI. Then down
below in the text it says — again, this is on the CMS website — once you
obtain your NPI it is estimated that it will take 120 days to do the remaining
work to use it. This includes working on your internal billing systems,
coordinating with billing services, vendors and clearinghouses and testing with
payors. So we are already behind, and that is not going to be feasible.
Another thing that I noticed on this same webpage is, it also says, when
applying for your NPI, CMS urges you to include your legacy identifiers not
only for Medicare, but for all payors. If reporting a Medicaid number, include
the associated state name. This information is critical for payors in the
development of crosswalks to aid in the transition to NPI.
If that was so critical information, why wasn’t this instruction included
on the NPI application to begin with? So I think we have a lot of issues
related to CMS in that regard.
Regarding all these missing non-chain pharmacies in the NCPDP database,
NCPA would be willing to communicate directly with those pharmacies in order to
encourage them to apply for the NPI application, but to date that list has not
been made available to us.
Other independent pharmacies related to NPI, prescriber NPIs. I think
Michele already talked about this. One thing is, in the health care claim
transaction format that we use for retail prescription drugs, which is the
NCPDP 5.1 telecommunications standard, this standard requires a prescriber ID.
It requires a type one NPI, not a prescriber type two NPI. So pharmacies will
not be able to determine if they are receiving the correct prescriber type one
NPI as opposed to the type two based on the information currently available to
us. So as a result, claim rejections will occur if the type one NPI is not
submitted, but the drug claim. If this occurs, pharmacies will have to contact
prescribers and we are likely to encounter those prescribers that are certain
they have provided us with the correct NPI.
To assist with this potential problem, like Michele said, CMS has to make
the NPS prescriber NPI database available and the dissemination rules sooner
rather than later, if it is not too late already.
Prescriber NPIs. This also is another concern that just recently popped up
a couple of weeks ago. We were made aware of the fact that prescribe system
software vendors have not fully implemented the check digit algorithm to also
validate prescriber NPIs. So this is something that is not implemented on a
widespread basis yet in our industry, which would help, of course.
Another pharmacy concern regarding prescriber NPIs is, how will pharmacies
obtain the prescriber NPIs. Michele mentioned this also. Should we use the
central CMS database or should we contact our prescribers directly? We are
telling our members that it is dependent upon your situation, and the answer is
different if you are a large versus small pharmacy provider versus a chain or
single proprietor owned. It might be more beneficial to a large provider to
work with the CMS file directly.
Also what we are hearing is that it may be more difficult for large and
small pharmacy providers in large metropolitan areas to obtain prescriber IDs
directly from prescribers.
One overall comment. We think pharmacies would benefit form an online
solution for real time access to prescriber NPIs, or HHS could require
prescribers to impart their NPIs on the prescription at the time it is written.
Another concern about prescriber NPIs is, how will pharmacies submit claims
for prescription drugs from prescribers without an NPI, prescribers who choose
not to obtain an NPI or if they don’t use electronic health care claims
transactions. I know we have been hearing about this this morning, too. Our
recommendation is that health plans and PBM payor sheets should specify this in
their contingency plans.
One last concern about prescriber NPIs is, the NPI could be used for
Medicare electronic prescribing transactions, but it lacks of locator indictor.
This is not in the handout, but this was just brought to my attention yesterday
so I included it in my presentation here.
The NPI is an excellent choice for identifying who the provider is, and HHS
could require this for its Medicare e-prescribing program. However, there is
this problem where the location identifier is needed in order to route the
message to a prescriber. This is because many prescribers work in multiple
locations, so the message would not be able to reach the prescriber unless the
location was identified for the provider.
Currently, since this location information is not a part of the
e-prescribing transaction standard, it is likely that another provider ID would
have to be developed as it currently stands for this type of transaction.
There are also claim format challenges related to the NPI. The NCPDP 5.1,
the transaction standard for prescription drugs, it has no data field to
accommodate secondary identifiers for pharmacies and prescribers. So there is
only one data field for the pharmacy ID. It is not possible to send both an NPI
and a pharmacy legacy ID. There is also no data field to accommodate the health
care provider taxonomy code, versus the X-12 N837 professional can accommodate
multiple health care provider taxonomy codes and secondary identifiers.
Another independent pharmacy concern is whether or not pharmacies will have
to maintain dual provider identifier databases and dual business processes and
systems. This is because the small health plans are not required to implement
NPI until the following year, a whole year apart. So the pharmacies have to
maintain separate databases for both these legacy provider IDs that might be
continued to be used by these small health plans, and also that would be for
both pharmacies and prescribers. Also, what about the prescribers without an
In terms of industry readiness, our perspective is that this May 23, 2007
deadline is questionable, due to the lack of a fully enumerated industry,
particularly for non-chain pharmacies, due to the lack of guidance from CMS on
dissemination of its NPI database. We need adequate time to finalize
implementation plans between trading partners and also business associates need
adequate time for NPI testing to insure system changes and modified business
So our recommendations would be that CMS should still not allow any health
plans or processors to be able to request an NPI from providers prior to the
implementation dates. The payor and claims processor community should be
required to continue to accept pharmacy and prescriber legacy identifiers
beyond the May 23, 2007 NPI implementation date. And CMS should no longer delay
dissemination of its NPI database and guidelines, so that pharmacies and
processes can make the appropriate crosswalks and testing that is needed.
That concludes my comments. Thank you very much.
MR. REYNOLDS: Annette.
MS. GABEL: Hi. My name is Annette Gabel. I am the Executive Director of
Industry Standard Compliance for MEDCO Health Solutions. MEDCO is a manager of
prescription drug benefits. MEDCO provides prescription benefits for more than
seven million of the approximate 43 million Medicare eligibles nationwide.
MEDCO also has a mail order business, which is one of the largest pharmacy
operations in the United States. In 2005, MEDCO managed 540 million
prescriptions, including more than 87 million which were dispensed through mail
I am here to explain the training we completed on NPI, provide a current
status for both our PBM and mail service business, where we think the industry
is as far as being ready for the NPI implementation date, and the issues that
we will be placed with if the change is not made to the required date of May
As far as training and outreach is concerned, we distributed payor sheets,
which basically are claims submission instructions to the pharmacies. So we
send payors to the pharmacies and indicate to them what will be required on
their claim transactions, when we will start accepting the NPI and when we will
start rejecting claims which do not contain the NPI.
We invited pharmacies to test their software for NPI submission. I can
reprot that as of the 19th of January, we only had seven software vendors who
had successfully completed testing. We have currently not had any testing
completed with any of the chain pharmacies or the independent pharmacies. We
are thinking that the reason that that is is because we are requiring the
physician number in the transaction.
We have trained our customer service representatives to respond to
inquiries from pharmacies, and we update that training monthly as issues arise.
What our current status is, as of the tenth of January, we began accepting
either the NPI or the legacy identifier for pharmacies and physicians on the
NCPDP 5.1 claim transactions. As of January 12, our MEDCO mail service
pharmacies, who had already been enumerated in 2006, began submission of NPI to
any payors that were able to accept. Currently that is just MEDCO.
As of January 19, we are providing some statistics for what we are seeing
on the retail transactions. So for the period starting on the 12th of January
through the 18th of January, we processed a total of 7,514,064, and these are
retail claims only, and the total claims we received with pharmacy NPI were
10,375. That percent of our total claims was .14 percent. The total claims we
received with physician NPI was only one.
MEDCO has implemented their NPI logic earlier than most, and it is obvious
based on the data we pulled that pharmacies are in a much better position to
submit their NPIs than they are to submit physician NPIs.
As far as readiness, we feel that the pharmacy is not ready for the
compliance required for NPI. Reasons being, not all HIPAA covered pharmacies
have been enumerated, pharmacies do not have a complete and reliable NPI source
due to the lack of data dissemination information, their website lookup
capability cannot be built because it is contingent upon the data dissemination
policy, and then once the data dissemination is available, mapping from the
pharmacy DEA to NPI will be difficult, because on the requirement of the NPI
application it was not required that alternate IDs like DEA be provided on the
We are finding that pharmacy staff have not been trained. In situations
like ours, where pharmacies have national coverage, one-off lookups or
physician outreach is not feasible. Both volume, cost and lack of motivation
and understanding at physicians’ offices as to why the pharmacy or PBM is
We made some calls back in December, and we found that for every five calls
that we made looking to get physician NPIs, only one out of five offices
understood what the NPI was and could provide the physician NPI.
The lack of data dissemination policy has made it impossible to plan an
approach for developing a crosswalk between legacy IDs and NPI. If a
dissemination notice is not released soon, it still leaves less than four month
to code and test. A real test would require the NPI file, so when the
dissemination notice comes out, will it include the date that the file will be
As far as issues, MEDCO has taken the approach that come May 23, 2007 for
the Medicare Part D transactions we will be rejecting claims that do not
contain NPI for both the pharmacy and the physician. That could very well
result in 43 million Medicare eligible beneficiaries going without their
medication, or they could be forced to pay cash at the counter.
Pharmacies are not equipped to handle the beneficiaries’ complaints. PDPs,
health plans and Medicare customer service will incur increased call volume,
creating additional costs in delivery of the pharmacy benefit. We will have
increased member service complaints, increased member grievances for delays,
and increased number of appeals for denial of payment.
Medicare beneficiaries will escalate claim rejection issues, increasing
skepticism on the effectiveness of the Medicare prescription plan. Physicians’
offices will see an increase in faxes and calls from pharmacies trying to
obtain NPI, while members are standing at the counter facing a claim rejection.
The other question is, have physician staff been sufficiently trained to handle
these calls. Increasing talk time for physicians will definitely add costs
So I believe that the industry agrees, hearing from everyone that has
testified today, that there is going to be a major impact on claims processing
come May 23, 2007. I don’t think anyone here wants to impact patients getting
the health care that they need.
So we are requesting, as you have heard from everyone else, a quick release
of the dissemination policy, a date for the availability of the file, and a
reassessment of the requirement of NPI being present on claims on 5/23/07.
MR. REYNOLDS: If people weren’t awake after lunch, you woke them up with
that one. John.
MR. LAVIN: John Lavin, Vice President of Industry Relations for Caremark,
similar to MEDCO. We are a large PBM, large Medicare plan PDP, as well as a
pharmacy, mail order specialty and some retail pharmacy. So we cross the gamut.
I’m not necessarily going to go through each slide, because a lot of this
stuff has already been said. I think what Annette had said was very important.
But there are a couple of items that we have taken a slightly different
approach on a few things.
As a PBM, we have been going through and testing all of the software
vendors that provide software out to the pharmacies and going through the top
40. That covers most of the claims that are submitted to us. We did 25 in
December. They all passed. There were some various problems. Those have been
resolved. Took a break for one-one implementations, and then started up again,
and we will finish this month.
My assessment there is that the software vendors for the most part will be
ready to go, from setting claims and receiving the 835s. So that is not
necessarily the issue, I don’t think.
On the pharmacy side, we have also been doing testing. Some of those are
major chains that also have their own software, so we consider them vendors as
well. The testing there is going well like it has with the other vendors.
I feel comfortable from the chain side submitting their own pharmacy NPIs.
They would be able to do that by May.
On the independents side, I put this down as a yellow for the industry. On
the independents side, it is a great concern. I think Kathryn actually went
into it pretty well with the numbers.
Going back to your questions, could they be ready by May, if that is the
real question, I think they could be, quite frankly. I think they could be as
far as submitting their own — there are a couple of things that have to be
done. First, they have to go out and get it. NCPDP has stepped up as far as the
bulk enumerator, but there is only a certain amount of time, and I know they
have certain limitations, so they have to get those done very quickly or they
will not be ready and be disseminated.
If that is the case then, the pharmacy will have to go to every individual
payor and give them their NPI. If they go through NCPDP, that will be
disseminated to most of the payors or PBMs. So we are encouraging them. I know
there are other organizations as well.
It is getting to the point now where I think they are really starting to
understand, if I don’t do this, then I will not get paid. That is usually a
pretty good indicator.
Going through Y2K and then also to 5.1 implementation for the telecomm
standard, there will be some on the particularly independent side that just
will not do it until they get a claim reject. That is just the bottom line. You
can call them, you can beg them, threaten them, whatever you want to do. Until
they get the first claim and they call the health desk and start crying, then
they will get it done as quickly as they can. So they have cash flow problems,
member problems. So we are going to try to avoid that.
That tends to be a pretty small number. My estimation would be a couple of
thousand, perhaps. So I think as an industry we need to focus on that. We will.
I think I have asked NCPDP to do that as well. But I am still cautious as to
whether we can get that done without great inconvenience to a lot of members.
The other is the prescriber ID. I’m not going to beat a dead horse here. I
think there has been a lot of testimony where that is. That has been the great
From our perspective, from Caremark, we were not going to require
prescriber IDs. It is an optional field in the 5.1 claim. For the most part we
will still accept the legacy ID. But we have a couple of problems with that.
Number one, without a dissemination, without a cross reference, if we start
getting NPIs, we don’t know how to cross reference that to our legacy numbers.
So there is going to be clinical issues. We are not going to know who
prescribed that drug, and that is very important to a lot of things we do.
Patient safety issues, prior auth issues. So that needs to be done. We need the
dissemination rule, and we need to have access to the physician NPIs.
Secondly, there are going to be certain clients, and I think Annette hit
that pretty strongly, certain clients, and particularly Medicare Part D being
the largest one that we have, as the regulation stands today, we have to reject
the claim if it doesn’t have an NPI. That would be in the prescriber field as
well as in the pharmacy field. That will be a great disruption to the program.
I haven’t heard anything that they have sent anything out to the contrary.
So we are waiting for that. We have asked CMS for clarification on that,
but without the dissemination rule and without having any access to that data,
it is a great concern.
I think going through your questions, what should we do, what should be the
recommendation, on the pharmacy piece I am concerned about going for a May 23
implementation. I think it could be done. There will be some pain, but I think
it could be done on the pharmacy side. Quite frankly, on that side we are going
to have to hit that road one time or another. If we do it in six months, we are
going to have certain pharmacies that we are going to have to call, we are
going to have to cajole and get that number out of either way.
On the prescriber side, I think any of the clients that are going to
mandate that, we will definitely recommend that they not do that, because they
will just see great disruption. Secondly, as PBMs we do not have direct
contracts with those physicians, so it is very difficult for us to get that
other than through the NPPES system or a data vendor who collects that data and
distributes it to us.
On top of the dissemination rule coming out, it really needs to provide
adequate access so that we and also the pharmacies can gather that. Trying to
gather it prescription by prescription or making phone calls to physicians is
not going to be an efficient way to do it and will cause chaos. So I think the
dissemination rule has to allow for that to happen.
That is it from me. Thank you very much.
MR. REYNOLDS: Questions from the committee? I will start out. Kathryn, I’ll
start with you. My question is, as we heard earlier from some of the
presenters, the smaller providers and in your case the independent pharmacies,
are the ones that everybody can’t seem to get to. They will be with us through
many, many other implementations. Are there any words of wisdom you can give
the committee, or let’s just put this one aside because we know what we are
doing, as to how in future implementations we make a difference.
It appears more and more that this ability to get out and reach the smaller
of the players is going to decide a whole lot, especially when we deal with
pharmacies, because they are the prescribers of a lot of medications, and
especially a lot of medications through some of the government programs also.
So if you could give us any words of wisdom, and if they are really good,
we will write them down and use them.
MS. KUHN: There definitely are ways to address our current problem with
NPI. For example, as I mentioned with the NCPDP database, we know which of
those pharmacies have not provided an NPI. So there is a way to reach out to
them, either through a fax or mail or e-mail, to remind them that this is it,
otherwise you are going to have a disruption in claims payment.
That list currently to date has not been made available to us, even though
we have requested it. So that is a problem. But there is a way that we could
help in that regard.
Of course, the prescriber NPIs are still a problem for the pharmacy claim,
particularly with the Medicare program. So there are issues that can be
specifically addressed with our current problem.
MR. REYNOLDS: John and Annette. May 23, and you have both made it pretty
clear that you consider that a wall, a hard stop. Is that because of the
regulation or is that because of something that is in Medicare Part D?
MS. GABEL: In my situation it is in Medicare Part D.
MR. REYNOLDS: And it says?
MS. GABEL: And it says that all Medicare claims must be submitted with the
NPI on 5/23/07.
MR. LAVIN: I agree. That is the one issue. The other issue is the
independent pharmacy community for the pharmacy. It is just a lot of work
between now and then.
I think MEDCO was one of the first payors I know to roll. We are going to
start allowing NPIs coming in next month. I know Express Scripts is also in
that time frame, and Wellpoint, and there are a few others. So I think they are
going to be able to start submitting those. That provides one thing the
pharmacies can start doing.
Secondly, it will allow the payors to start identifying who is not
utilizing. That I consider my control countdown, where you can start
identifying who has not — call the pharmacies, we see you are not using your
NPIs, what is happening.
So on the pharmacy ID, it is not the regulation. It is just the education.
It is getting the independent pharmacies motivated to get that information.
MS. GABEL: Just to interrupt you for a second, John. One of the things that
I have been hearing though from some of the chain pharmacies is, until they
have their systems ready to submit the NPI for the physician, they are not
going to submit NPI. I have been hearing that. So that is a concern as well.
MR. REYNOLDS: That is that single cutover.
MS. GABEL: Right. They don’t want to code twice, they want to code once.
MR. LAVIN: That is a concern.
MR. REYNOLDS: I’ve got plenty of questions, so if nobody puts their hand
up, I’ll keep going.
Back to one of our key questions that we have, by May 23 your constituents
ought to be able to get NPIs. There is nothing that you need from anybody else
to make that happen. I didn’t say the prescribers, I said the constituents,
which will be the pharmacies. I don’t think I have heard anything from anybody
that says that is not a fact. Everybody good with that?
MS. GABEL: Yes.
MR. LAVIN: Yes.
MR. REYNOLDS: Is there any reason that any of you could not be testing by
MS. GABEL: No, we are testing now.
MR. REYNOLDS: No, I understand. I am going back through very structurally.
I heard the testimony. I wanted to see the heads nod a little differently this
MS. VILARET: The only thing that we are waiting on is the corporate NPI. It
is because we are waiting on information from CMS.
MR. REYNOLDS: So that is the first thing that we have heard as a committee
that is actually a possible physical block to anybody that has been talking to
us, that they couldn’t be testing.
MS. VILARET: And it is not for testing. It is just, if we need an
additional NPI and it is a corporate NPI for the 335.
MR. REYNOLDS: But you could be testing dates?
MS. VILARET: Yes, we are testing —
MR. REYNOLDS: Thank you for the clarification.
MS. VILARET: It is just an additional NPI.
MR. REYNOLDS: In this case you guys are the payor philosophically, because
as the PBM you are the one that is pretty much clearing the claim wherever you
get your final money from, whether it is your own company or somebody else.
I think the one thing that yours and other testimony has really made clear
to me that I probably didn’t understand the magnitude of, just working for one
payor, is this whole idea of where you have rendering physicians, referral IDs,
and now prescribers. That ability for everybody to group up and know about
everybody else is probably something that I have gotten a significantly
different look at today than I had.
If you really think about it, it started out as one to one. I think one of
the lessons we can learn going forward is, oversimplifying the words, every
heartbeat has to get a number. We see that is a fairly easy discussion. But how
many heartbeats do you have to personally take care of which are your
prescribers and your other things, is bringing a whole new complexity into this
that is based on what is available, what is not available, what databases you
can access and what you can do, has dramatically driven this thing to a
different position than those words would have let on as you were going through
the implementation. Is that a fair statement?
MS. GABEL: I think so.
MS. KUHN: Definitely. We have the same problem.
MR. REYNOLDS: Any other questions? Michael.
DR. FITZMAURICE: As I listened so far today, I hear that the problems seem
to be that there is no NPPES for validating NPIs, for obtaining NPIs of
prescribers, and generally testing payment systems. The problems are that
physicians are not getting their NPIs, maybe pharmacists are not getting their
NPIs, or pharmacies, and physicians not supplying their NPIs to health plans
and providers. That may be tue for pharmacies and pharmacists. Also, vendors
not getting their software up to handling the NPI. This may extend to any
electronic prescribing users.
My question is, how much of the problem will go away on the date and soon
after that the NPI is available? And how much problem will still remain? Here,
the database is available, but it is still going to take some time to do all
this testing, right? So how much will go away with the NPPES is available and
then what do you need to do?
MS. VILARET: Once we get the magical database, it depends what is on the
database, of course, and it depends what type of file it is. Hopefully the
database is cross referenced in some way, but most likely it is not going to be
cross referenced to any kind of other identifier.
DR. FITZMAURICE: You mean like a UPIN.
MS. VILARET: Right. So it will have the UPIN to cross reference it to, and
then we will have to match it up in our system. Then what the pharmacies will
have to do is put that into their system and use that as their regular
Now, the biggest problem with that is, it is going to be the master
universe, and it is probably going to be way larger than what the pharmacy is
going to need, so they will have to pare it down. That is where I referenced
the 180 days. It could take up to 180 days probably for the pharmacy to be able
to make it a usable database and be able to figure out how they are going to
use it and get it into their system and then get it out to their stores, and
then be able to work it into their software.
DR. FITZMAURICE: It would help if this NPPES were classified by, here are
the pharmacies, here are the pharmacists, and then here is everybody else?
Would that help you pare it down?
MS. VILARET: It would definitely help us pare it down, especially if it
were prescribers by state. If there were some way for them to say here is a
Virginia file, so you could say, I need a Virginia file only. There are
regional providers, there are chains that would love a national list or
It is a monumental task, but still it is going to be dependent on the file
format of the file, and they will still have to work it into their system.
MS. GABEL: I had one comment. If you are a pharmacy that is not currently
doing Medicare Part B, then UPIN is not going to help you with the cross
DR. FITZMAURICE: That is a good point.
DR. FAVERO: DEA would be nice to have as a cross reference. I don’t know if
that is a possibility, but we have been fighting that for years. For the most
part that is what the industry utilizes as the de facto standard. So to make it
as easy as possible, that would be the cross reference.
MR. REYNOLDS: A followup on Michael’s question. But even when the NPPES is
available, any other provider that is a prescriber that doesn’t have their
number still leaves a hole in your process, correct?
MS. GABEL: Yes.
DR. FITZMAURICE: Have there been discussions with CMS and the industry
about the kind of file that you like? Or does CMS know the kind of file you
DR. VILARET: They haven’t even asked. There has been not any kind of
MS. GABEL: I think early on there was, though. When we commented on the
construction of the NPI file and the application and the data that they were
gathering, we commented on the things that we would like to see on the file. So
way back when, yes, that information was provided.
DR. FITZMAURICE: So that information is known.
MS. GABEL: Yes.
DR. VILARET: I know that NCPDP is one of the organizations that has been
working on obtaining that type of file. They would be an organization that
would be very good at getting that type of cross reference file, because they
have the UPIN and other types of identifiers. They would be able to easily
cross reference it and put it into a more usable file format for the different
DR. FITZMAURICE: Some of what I thought I heard from previous panels was,
if we just started off with, here is the name and address of the physician or
pharmacy or pharmacist and here is the number, that would be a good start. Then
you argue about the confidentiality of the rest of the information.
You have said you would like to have a cross reference with the UPIN, it
would really be nice to have a cross reference to the DEA but it probably won’t
happen. Is number and name and address sufficient to get started?
MS. VILARET: Personally I would rather use DEA, because DEA is the number
that we go by as the identifier for everything.
DR. FITZMAURICE: But there is a push not to use the DEA number by —
MS. VILARET: It is actually by the DEA, but all the files that we have
currently, that is what we use to identify the prescriber right now.
DR. FITZMAURICE: That is practical.
MS. VILARET: Be it right or wrong.
DR. FITZMAURICE: Thank you.
MR. REYNOLDS: My last question. If this thing goes past May, what is the
structure for — and I heard clearly what some of your wall looks like, and
that appears to not be something that this committee can deal with necessarily.
But if it were, what kind of structure — you guys are implementers and you do
these things, what kind of structure do you see in tracking this thing, whether
it is 12 months, six months, two months or an hour and a half?
We need to have some kind of structure on how we deal with it after May 23,
if that is the recommendation. So any comments you can make, I would
appreciate. I understand my right side of the room has limitations, but we are
not talking about those limitations. We are asking for input.
MS. VILARET: I actually gave it to you. I would do a slow implementation,
where the final goal would be one year from the time that we get the
dissemination notice and the file. The key is getting the actual usable file,
not just the dissemination notice. The missing piece is the prescriber file.
But once we get that information and we can start working towards sending
the prescriber numbers, then I feel that we can start slowly sending these
numbers and have a slow rollout and turn the plans on on a rolling basis. We
can work with AHIP and work with the different plans.
The biggest thing we don’t want to do is turn on all the plans at once,
because that would be the biggest disaster. If we have a hard cutover all at
once, then what we have is a huge impact on customer service, and we don’t want
to have any kind of service disruption. That is what we want to avoid.
I think that we can with the plans watch how many claims are coming through
with NPI. We are very good at doing messaging, if that is possible, or at least
encourage pharmacies to send the NPI and do it on a rolling basis, say a three
month, six month, nine month. But we just don’t want everybody 12 months from
now to go wide with the NPI.
DR. FITZMAURICE: I wanted to follow up on Harry. Suppose the judgment came
down from on high that you get an extension of six months from the date that
CMS puts out the NPPES and the guidance. Could you live with that? You are
talking about three months and three months and three months; can you do it two
months and two months, and here it is?
MS. VILARET: The thing is, we still have to be able to use those files. I
think six months wouldn’t be enough time, because remember, we still have to
implement those files. That is why we want the 12 months.
DR. FITZMAURICE: So there still may be some back and forth between CMS and
what the industry needs.
MS. VILARET: Yes, because we still have implementation time of being able
to use those files. That is why I really want the 12 months.
MS. GABEL: I think that you really need to know what is going to be
provided, because if you don’t for example use the DEA to create a cross
reference, you have a lot more work to do.
MR. REYNOLDS: Is it safe to say from a pharmacy standpoint that you have no
jurisdiction over when the prescribers get their number, and therefore your
only recourse, whatever this transition period may or may not be, is to deny
claims at some point?
It is different than some of the other people we have heard from. You are
associations that deal directly with those people. You are pretty much a
secondary industry to that number, is that fair?
MR. LAVIN: I think that is accurate. Most of the PBMs, some are also
medical providers and they would have direct relationships, but not necessarily
with every physician who can write a prescription for them. So I think even in
a lot of the plans, they don’t necessarily have control over every physician
who is going to write a prescription for them.
MS. KUHN: That would impact both our prescription drug claims and our
professional claims, so both sides.
MR. BLAIR: I believe I understand that you have indicated to us that the
only consequence you have, if you don’t receive from prescribers their
prescriptions with an NPI number, is to deny claims. However, from a business
standpoint, wouldn’t there be great reluctance to resort to that?
MS. GABEL: Yes, there is definitely great reluctance. But when you are
operating as a prescription benefit manager and you are complying with a
client’s requirements, you really don’t have an option. It is up to the client
to remove the requirement, and then you can prevent the business disruption.
MR. BLAIR: How do I want to phrase this? I am trying to separate out, if
the rules say it should happen, I am asking whether you think it will happen.
MR. REYNOLDS: I think what they said earlier, Jeff, was, this isn’t about
the regulation, it is about the contract between them and CMS for Medicare D.
That is the issue here. So it is not about the regulation, it is about their
direct contract as Part D PBMs with CMS. That says that as of a certain date,
something has to happen.
MR. BLAIR: Thank you for the clarification.
MS. VILARET: It is actually in the final rule. If you read the final rule,
it says that that could be a consequence of a prescriber not having an NPI.
Unfortunately it puts the burden on the pharmacy, and then the pharmacy has to
call the prescriber and then you can either charge the customer cash or — of
course, we are going to call the prescriber and ask the prescriber to obtain an
NPI at that point. If the prescriber refuses, then the customer will have to
pay cash. Hopefully the prescriber will decide to contact CMS online and obtain
their NPI. Then we will be able to process the prescription after they obtain
their NPI. But meanwhile, the customer waits until they do.
MR. REYNOLDS: We thank you very much. We will get back together at 2:45 and
continue the trip. Thank you very much.
Agenda Item: Panel IV – Plan/Payor
MR. REYNOLDS: It has been a long day, but this group is going to cover a
few things. Then as I look at my agenda, WEDI has all the answers. So we are
really excited. So those of you that have been worried, at 4:15 WEDI has got
all the answers for us. So hang in there with us, we are almost to the end.
The group that we have now is the plan/payor group. We are going to start
off first with Marilyn, if you would introduce yourself, and then we’ll go
through your testimony. Thank you.
MS. LUKE: Harry, thank you, and to the full committee, thank you for the
opportunity to testify today. While I have been attending the NCVHS meetings
for the past three years, this is my first time testifying, so I certainly
appreciate the opportunity, and I am glad to do it.
I am here today to report on the status of HIPAA/NPI implementation among
health insurance plans. I represent AHIP, which is a national association. We
have over 1300 health insurance plans, and we provide coverage to more than 200
We offer a broad range of products in the commercial market, which include
health and long term care and some other products, but we also have a proven
track record and have been committed to participation in public programs such
as Medicare and Medicaid. Virtually all of our members are covered entities for
the purposes of HIPAA, and they will be required to comply with the NPI
My testimony today is going to talk about the issues that remain
problematic as plans continue to work toward the NPI implementation date. I am
going to offer what our members feel would be an appropriate recommendation to
help solve some of the issues that remain.
Since the final regulations were published, the health plans have been
doing a number of things to try and make sure that they implement the
requirements in an appropriate time frame. That included everything from
evaluate software packages, starting to build crosswalks and continuing to
enumerate their crosswalks to associate historic identifiers to the new NPI.
They have done a lot of work in outreach to providers, educating those
providers that they contract with about the NPI requirements to get them up to
speed, and in some cases the plans have reported that they have actually begun
testing to make sure that the NPIs will work in the electronic transactions.
In preparing for my testimony today, we conducted an informal canvass of
members. It was by no means statistically valid. Plans were not obligated to
participate, it was on a voluntary basis, and we didn’t use any kind of formal
methodology to verify the results. But I can tell you that generally, the
feedback that we received was, about 75 percent of the health insurance plans
that we spoke with were plans that represented individuals of 250,000 lives or
more by entity. Of these responding plans, a third of them estimated that they
are between 60 and 100 percent finished in implementing the NPI requirements.
MR. BLAIR: When were your asking the questions?
MS. LUKE: We had conducted the survey in December, and we completed the
survey results probably the second week in January.
Of the plans that responded, 40 percent of them said that they are
currently testing electronic transactions with their trading partners.
We are encouraged by these results. We feel it exhibits the commitment that
health insurance plans have in meeting the NPI requirements. But we are not
confident that as of today, all of the requirements will be successfully
implemented by HIPAA covered entities by the compliance date of May 23. That
has been caused by a number of external factors that have delayed the
I guess in summary, the plans aren’t where they expected to be in their
implementation plans by the time — as of today. So I can identify a number of
the factors that have caused these delays, but it is really a lot of the
information that you have already heard.
When the final regulations were initially published, plans expected to have
a data dissemination policy that explained how the NPIs would be shared and
used. That has been delayed, and we would urge that that be released as soon as
MR. BLAIR: Can I just interrupt for a sec?
MS. LUKE: Sure.
MR. BLAIR: Because it is almost like going down a pattern and a sequence.
This is perfect, and I don’t want to miss a step here. Did your survey also ask
the question as to what percentage of the plans would be ready by May 23? If it
did, we would also like to know what that number is.
MS. LUKE: Jeff, we did not ask that question.
MR. BLAIR: That’s okay.
MS. LUKE: I can tell you that because the data dissemination policy has not
come out, our plans have had to devote a number of administrative resources to
work with individual providers to get the NPI information. It has been
cumbersome and time consuming, and some of the plans have reported that they
are still in the process of gathering information.
They have also reported to us that providers in some cases have been
reluctant to share their NPI information, because they mistakenly believe that
they have to guard their NPI to protect themselves from things that we heard
earlier this morning, such as identity theft.
So given these factors, I think it is unreasonable at this point to expect
all of the HIPAA covered entities to comply with the compliance date of May 23,
because this critical information has been lacking.
We also think that to date, provider enumeration has been lower than
anticipated, although we recognize that that is very hard to quantify, because
of this requirement for enumerating subparts. Because subparts have been a
point of confusion within the provider community, many of them have had to seek
out professional and legal advice to understand how those requirements apply to
their individual situations. That has caused a problem with some of the
providers and has delayed them from getting an NPI.
So what we anticipate is that there is going to be a significant number of
providers who receive their NPIs on or near the compliance date, and that puts
the health plans in an awkward position, because we will not then have adequate
time to complete the testing and building of our crosswalks that are going to
be an essential key to effective transaction processing.
We don’t want claims payment issues to result. So what we are recommending
is that the NCVHS consider holding providers to the compliance date of May 23
to get their NPI, but we would like to recommend a contingency period for all
HIPAA covered entities until November 23 to begin using NPIs in electronic
transactions. We feel that this reasonable but short period of time will allow
entities to continue to work together and insure that the transactions can be
MR. REYNOLDS: Marilyn, before you go any further, are you saying hard stop
of November 23?
MS. LUKE: Yes. I am going to get to my next recommendation, which is —
MR. REYNOLDS: I wanted to make sure I understood.
MR. BLAIR: Could you repeat also what you said would we do November 23. I
missed a word in there.
MS. LUKE: As of today, we are recommending that all HIPAA covered entities
be given until November 23, 2007 to begin using the NPI in electronic
transactions. We would like the NCVHS however to hold additional hearings in
perhaps three months or in the fall later this year to reassess the industry’s
performance and progress, and see if we need any additional time at that point.
So we are not advocating for a flat-out 12 month period or a period of time
from the time that CMS may release the data dissemination policy. We are asking
for six months after the current compliance date, and a reassessment to see if
any additional time would be needed in the future.
That summarizes my main recommendations. I certainly am available to answer
any questions that you may have. I thank you again for the opportunity to
MR. REYNOLDS: Thank you. Justine.
MS. HANDELMAN: Good afternoon, and thank you for having me here. I am
Justine Handelman, Director of Federal Relations for the Blue Cross Blue Shield
Association. I am here today on behalf of Joel Slackman, who had some other
things that had come up and did not allow him to be here. Sitting next to me, I
just want to recognize Bill Olfano, who is our policy technical expert in this
area. Being that I am sitting in for someone, I wanted to make sure I had a
real expert with me.
As I mentioned, I am with the Blue Cross Blue Shield Association, that is
made up of 39 independently owned and locally operated Blue Cross Blue Shield
plans across the U.S., which collectively provide health care for one in three
Americans, or 98 million Americans. On behalf of our plans, I would like to
thank you for the opportunity to be here today.
While progress is being made, much more does need to be done if the
industry is to meet the government’s deadline of May 23, 2007. With respect to
the questions that were posed by the subcommittee, I would like to highlight
the following points.
First, Blue Cross Blue Shield plans are working diligently to be able to
process NPI-only transactions on the May 23, 2007 compliance date.
Second, our plans’ top concern is the low rate at which providers are
getting their numbers and communicating those numbers to health plans. This has
significantly set back testing schedules. In addition, the lack of a national
plan and provider enumeration system data dissemination policy that defines
both the data that will be available and how the data will be made available
has caused problems and delays.
Without access to this database, plans cannot easily validate the accuracy
of the NPI reported to them by the providers, and more importantly, cannot
identify and do outreach to providers that may have obtained their NPI but not
yet reported it to plans.
Third, because we believe extensive outreach, including educational
materials and multiple repeated contacts with providers will yield positive
results, Blue Cross Blue Shield plans have worked hard to expand our provider
outreach, particularly over the last several months.
Fourth, I would just like to say that we do not support extending the
compliance date. At this time, we do believe that all providers need to
continue working toward reaching compliance. We don’t want anything that would
slow that down. We want to get as many on board as we can at this time.
However, as the date gets closer and we realize that this might be
unrealistic, which as we have heard today is becoming more and more apparent,
we do think that options do need to be considered as to what kind of
contingency and what limited period of time would make sense in order to reach
As you all may know, especially with the NPI, a HIPAA mandate may seem to
be simple. This one appeared to be simple, obtaining a number and passing that
number on to payors. But complexities invariably do surface, as we have
As I mentioned, our top concern is the slow rate of enumeration and
communication with plans. In looking at implementation plans, most of our
health plans have looked at originally being able to have earlier access to the
data dissemination policy. They have thought that at this current time where we
are right now, that numbers would have been secured by most providers, would
have been communicated to trading partners, verified and crosswalked, and that
most of the plans’ efforts at the is current time would be in testing.
But that is not where we are today, as you well know. If a provider does
not have an NPI, then it can’t be reported. If it can’t be reported it can’t be
crosswalked, and if it can’t be crosswalked, you know it can’t be tested.
Receiving NPIs from the provider is critical. It enables plans to build
crosswalks to their legacy numbers. Constructing crosswalks is very time
consuming, and it is complicated, and the results must be thoroughly tested to
make sure that they are accurate with their trading partners. It is critical to
get these right, because odd numbers are tied to reimbursement for providers,
so of course if they are not done right you can imagine problems that would be
The lack of a dissemination policy as I mentioned has made it more
challenging. But many of our plans have since changed their original plan of
wanting to use that data and have been able to go on and choose alternative
paths, such as asking the provider for confirmation of their actual NPI. But
that has been difficult and has required more time and been more costly. In
addition, it is more difficult to do outreach without that data to providers
that may have retained numbers, yet not reported them.
In terms of industry readiness, intensifying outreach is vital, because
approximately right now 65 percent of provider NPIs have been issued, but only
25 to 30 percent of those issued numbers have been reported to plans. This
means that about 80 percent of the required NPIs remain to be received and
crosswalked by plans.
The rate of enumeration and communication of NPIs to trading partners and
the extent of trading partner testing needs to pick up significantly, as you
well know, to meet the May 23, 2007 date.
Following a dual use strategy transition will help plans continue testing
their crosswalk and resolving issues uncovered by that testing. To date, the
number of our plans that are receiving and processing live transactions with
NPI is relatively small. We have numbers about four percent. As you know, such
low percentage does not yield an adequate sample that is enough to identify
problems that may exist in transaction issues. But our plans are using even
that low number to see what they need to do to validate and adjust their
crosswalks and uncover operational issues.
For example, some issues that plans have reported to date based upon that
low sample of testing is that receiving Medicare crossover claims that contain
invalid NPIs. That problem is now being worked out and trying to be resolved.
We also have a plan that is having to stop remittance transactions with NPIs
for claims that providers have submitted with NPIs, because those providers had
not yet changed their systems to be able to process those remittances with the
NPI. We also have reports of receiving two different NPIs from the same
practitioner. That might indicate a possible problem with the NPS duplicate
checking logic that is allowing multiple NPIs to be issued to the same provider
in certain situations.
In conclusion, I would just like to end with a question. First, what would
it say about our collective ability to meet future more complicated HIPAA
requirements like the 5010 and ICD-10 if something like the NPI, which we
thought was more simple in getting and giving a number, cannot be done on time?
As I have mentioned, the slow rate of provider enumeration and
communication to trading partners, a relatively simple task, doesn’t give us
promise for meeting future challenges. What we would recommend is that this
process in going forward be thoroughly analyzed and looked at to understand
what could be done in the future better so that we can have future HIPAA
mandates and down the pike a better implementation process to get things done
With that, let me just thank you again for the opportunity to be here. I am
happy to answer any questions that the subcommittee may have.
MR. REYNOLDS: Thank you, Justine. We will hold our questions. Cathy,
MS. CARTER: Thank you. Thank you for asking me to be here.
My goal today is to give a status update on Medicare’s implementation of
the NPI. I am not going to be making a recommendation, but I am going to
provide information about what Medicare has been doing and is doing and where
we stand at the current time.
Medicare implemented NPI in four stages. I think three stages were out
there publicly. We have added a fourth stage because of things that have come
up since our original plan.
The first stage was effective in January of 2006. Stage one consisted of
accepting NPIs on electronic claims and other kinds of transactions. The NPIs
were only added to to make sure that they met the basic structure requirements.
We were not validating the NPI against a file of NPIs to make sure it was the
We were of course continuing all through this last year to accept claims
and other transactions with legacy only. On paper claims, we were accepting
only legacy numbers until those paper forms move over to the next version,
because they did not have a place for the NPI.
I have the dates here. The transition to the new version of the CMS 1500 is
April 2 of 2007 through May 22. That is the implementation phase, and the
transition to the UBO-4 is March 1, 2007 through May 22. During this period of
time while phase one was in effect, we were continuing to send the legacy
number on any remittance advice.
Stage two was effective October of 2006. The idea there was to use an NPI
to Medicare legacy ID crosswalk. Others have talked about that as well.
Medicare has a significant number of legacy numbers that we have been using,
and our goal was to develop a crosswalk from the NPI to the legacy numbers and
back again, being able to go both ways. So we would provide a means in this
file for the fee for service claims processing system to convert an NPI when it
comes in on a claim or other transaction to the legacy provider identifier.
Electronic transactions during this period of time, starting on October 1,
could be submitted with an NPI only, although we have been encouraging
submitters to continue to submit their legacy number as well.
As I explained, the revised paper form in terms of the dates that I
mentioned before, we would accept the NPI on those paper forms according to
when the new form was available, and those forms will accept the NPI and the
The electronic remittance advices and paper remittance advices and the
coordination of benefits electronic transactions will contain both the NPI, if
it came in on the original transaction, as well as the legacy identifier.
So that is what stage two was about.
Stage three is to be effective on May 23, 2007. At that point, as I think
others have explained, we would transition to the full use of the NPI on all
electronic and paper transactions, with the exception of coordination of
benefits sending the outbound transaction to the COB partners, because small
plans have an extra year to implement.
During this period of time, claims submitted both electronically and on
paper that do not contain an NPI would reject. Claims submitted with an NPI are
going to be checked against the crosswalk, and if the NPI is not on the
crosswalk, if we cannot find it on the crosswalk, then the claim will reject.
Claims submitted with the NPI only and a match is found, but it is a one to
many match, those claims are going to suspend for further manual work to
determine what the correct match is out of those one to many possibilities.
Stage four is something that hasn’t been public to this point. Effective
May 23, 2008 is when stage four would become effective. At that point, provider
legacy identifiers would no longer be sent out on COB transactions. Our concern
is, we don’t have any way of identifying who is small and who is not, so for
COB transactions, the plan is to send the legacy as well as the NPI out on the
At this point, the next thing I want to talk about is controlled testing of
the Medicare NPI crosswalk process. Stage two was effective on October 2, the
first Monday in October. We began at that time controlled testing. So claims
that came in with an NPI only as of that point, because we were accepting
claims with only an NPI, we obviously had to use the crosswalk because there
was no other way to process that claim. So we were fully utilizing the
crosswalk logic for those claims.
Claims that are coming in with an NPI legacy, and we do have an increasing
number, and I will get to the statistics in a second, we are continuing to test
that crosswalk logic and the process, and we are incrementally implementing the
full use of that crosswalk across all of our contractor environments. So it is
not happening one hundred percent at each contractor site. Claims that come in
with a legacy only during this period of time starting in October obviously are
bypassing that crosswalk logic altogether, because there is no NPI on the
I wanted to briefly mention provider outreach. We have done an awful lot of
outreach from the CMS perspective. There is a website, you have the website and
the information there about all of the things that we have done. It wasn’t just
outreach for Medicare alone; it was outreach for the broader health care
community. We have done extensive outreach and created educational tools for
Medicare and non-Medicare providers for how to get your NPI, and explaining
that we want the correct legacy number that they want to associate with their
NPI that they are getting to be included in the NPI database when they are
We also have a special section on the website housing Medicare
implementation, specific things about what to do for paper claim purposes and
what the timing is there, and the fact that we are as a payor recommending that
they continue to submit the legacy number along with the NPI.
As of a short time ago, we have started requiring that the NPI must be
included on the Medicare enrollment application. That would be or a new
provider to enroll Medicare, or anyone who is making changes to their
enrollment for whatever reason. They must include their NPI as part of that
process or the application won’t be processed.
In terms of the statistics, I have only included the last three weeks worth
of statistics. We started collecting data in November, and we have been getting
data weekly on the number of claims with the NPI only, and the number of claims
that are coming in with the legacy-NPI payor. As you can see at this point, as
of the week ending January 12, 8.82 percent of our claims are coming in with an
NPI and they may also contain a legacy, and .22 percent are coming in with an
NPI only. Those 45,000 claims that came in with an NPI only are largely from
In addition, just this past week for reporting purposes we began collecting
data about the number of unique providers. These providers that are listed here
that account for these 21 million claims that are coming in that have been
submitting NPIs, 68,000 unique providers according to our data are submitting
the payor, the NPI-legacy payor, and 3,300 providers are submitting the NPI
only. Those are unique provider numbers according to our claims that we are
checking and running through a program to collect these statistics.
MR. REYNOLDS: And that is roughly out of a population of two and a half
MS. CARTER: In terms of the Medicare population of providers? I didn’t
think it was quite that high. I’m not sure what the universe is. I thought it
was one-point-something million for Medicare purposes. I don’t have that
specific statistic with me.
MR. BLAIR: Is that per what, per year, per month?
MS. CARTER: The statistics that we have at this point relate to the claims
that came in for that reporting week. So the data does change from week to
week. That is why we were trying to determine, of the claims that were coming
in with NPIs, how many providers there are we talking about. So it is a
significant number of providers, significantly higher than I was expecting to
see, because this is the first week that we have collected that data. So 68,000
unique providers are submitting claims to Medicare with an NPI on them, even
though it might also contain a legacy number.
MR. BLAIR: That is per week?
MS. CARTER: For that reporting week. So I don’t know that you can say that
it would be every week, because some providers go on a weekly basis, some on a
monthly basis, and it would depend on which provider set is submitting for that
week. These are unique weeks. It is not a cumulative figure.
The next set of data that I wanted to explain is our crosswalk matches. I
think this will be of interest to people. This is unrelated — I have a note
here on the top of this chart that it is unrelated to the claims process. This
is our separate effort to do the matching between the NPI and the legacy
Out of 5.7 million legacy numbers that we are trying to match, and those
are from a variety of sources, the UPIN database, our OSCR numbers, all the
kinds of provider numbers that we give out, 5.7 million total, we have 3.7
million that have been uniquely identified. That is 65 percent almost that we
have matched, and we still have 1.5 million that are not matched at this point.
These numbers that I am giving you here do not relate to claims. They don’t
relate to those claims numbers. If you look at this unmatched percentage, we
cannot tell at this point how much of that is due to the provider not having
received their NPI yet or not having reported it to us perhaps, or our
inability to match the number because of data in the variety of databases that
doesn’t match. So at this point, I’m sure that some of that 26 percent
unmatched is due to both of those reasons. I just don’t know how much is each
The last slide is showing you the crosswalk statistics, the ones that I
just mentioned, but on a flow basis. You can see that starting out in November,
you can see the matching rate. So this is that 65 percent that I mentioned is
now as of January 12, as of last week or two weeks ago, and that number has
gone up slightly from where we first started, tailed down just a little bit
because we are still working on looking at our databases. Our legacy numbers
for example, because we do have some old data in there, we have been purging
stuff from our legacy database, which is skewing the statistics a little bit,
that is what that downturn was about.
That is the end of my remarks. I will be glad to take questions.
MR. REYNOLDS: I’ll ask a couple of questions, and then we will go back to
the whole panel.
There were a couple of things that you brought up. First, have you had
access to NPPES?
MS. CARTER: Yes.
MR. REYNOLDS: Has it helped? In other words, what we have heard from
everyone is, everyone wants it out, they say they need assessment things, so
you are the only ones that have used it to get some of the numbers that you are
talking about. So what has been your finding to date?
MS. CARTER: The findings are, according to the data that I showed you, we
have matched 65 percent of our legacy numbers. It has been a help, but it is
not simple to do that matching.
Again, we do not know of the unmatched numbers, how much of that is due to
the providers not getting their NPIs. I know the statistics that CMS — 1.6
million NPIs have been assigned. What we don’t know because of the Medicare
specific situation, we have one to many and many to one situations. So I can’t
tell precisely the numbers. Since I don’t know how providers are enumerating
themselves, how they are choosing to enumerate themselves, I don’t know
precisely what my universe is of NPIs that I am looking for.
MR. REYNOLDS: Since you are the one on the panel that is actually
implementing this, the other question I have is, how much has that HIPAA 1500
change and the UBO-4 change added to the complexity of making this whole thing
MS. CARTER: You are not referring to the paper forms?
MR. REYNOLDS: Yes, I am.
MS. CARTER: The paper forms, I don’t know that that has added to the
complexity. My understanding, and I am not an expert on paper forms, is that
the real changes there were to add the NPI capability.
We have not quite implemented either of those forms. The work that we have
been doing has all been on our electronic forms. So the statistics that I was
quoting about the eight percent have all been coming in on the electronic
With regard to NPI, implementing it has been simple, I think the point that
Justine made — I’m not sure I thought it was simple at the beginning, but it
has turned out to not be simple. There are an awful lot of policy questions and
issues that I know we have come across as a payor and other payors have come
across as well.
It isn’t just one field where you need the NPI. It is not just one field.
It is three fields on the claim where we are looking for those numbers. They
are having to do a crosswalk and a match on potentially three, many times two,
different NPIs on each and every claim.
DR. FITZMAURICE: You talked about the legacy identifier with the NPI
crosswalk. Is it possible to share that with the industry?
MS. CARTER: The crosswalk itself?
DR. FITZMAURICE: Yes. Here is NPI, here is the legacy number, here is a
file. We don’t stand behind it, but it is one we put together. What do you
MS. CARTER: The data dissemination policy needs to be published before
anything like that could be considered.
MR. BLAIR: It needs to be — ? I couldn’t hear the words.
DR. FITZMAURICE: It needs to be done.
MS. CARTER: Whether or not that kind of data could be given out, I believe
would be covered or should be covered or could be covered by the data
dissemination policy, which I assume has been the topic of some discussion
already today. I arrived here 35 minutes ago, so I was not able to hear the
MR. REYNOLDS: We will go through some other questions. Let me say what I
think I heard as bottom lines.
November 23, somewhere along the way, hard stop. May 23, rejecting claims,
MS. CARTER: It depends on what question you are asking. If you are asking
what was my recommendation, I did not make a recommendation.
MR. REYNOLDS: But you did make a statement of your position.
MS. CARTER: And my statement was simply, Medicare’s implementation plan for
the NPI. We had announced three public stages, and stage three was the go-live
date. That is still the plan, but I didn’t think it was appropriate for CMS to
make a recommendation about whether or not we should delay.
MR. REYNOLDS: No, and I am not pushing you to do that. I am making sure I
understood your words. So you are still shooting for May 23?
MS. CARTER: Yes, we are.
MR. REYNOLDS: And hard stop May 23.
MS. HANDELMAN: At this point we want to work towards that hard stop of May
23, but understand that may be unrealistic, and want to look at contingency
plans a little bit closer to the date. But at this point our plans don’t want
anything to hinder providers from getting enumerated and giving a number. They
want to try and keep doing as much as they can and look at this in another
month or so.
MR. REYNOLDS: So I won’t put Cathy on the spot to answer for CMS, but I’ll
ask the other two.
We have heard all day that segments of the industry may or may not be
ready, and more than likely will not be ready for the full-blown situation,
everybody working together by May. So Marilyn, as you look at it, and Justine,
as you look at it, what process do you see — again, I appreciate your words,
check it out in November and see where we are, but a lot of people wait until
November to see where we are and go on.
What do you see as any kind of structure — and Justine, I want to ask the
same thing, and Cathy, if you want to make a personal discussion about that, I
understand your position of not necessarily wanting to speak for CMS, and I
will not put you in that position if you feel uncomfortable there.
DR. LUKE: I think, Harry, the best way to answer that is to say that right
now, we should continue to educate providers and encourage them to receive
their NPI, apply for it and go through that process. Hold that process to the
May 23 compliance date. Then we need to allow the additional time so that
covered entities can continue to have some flexibility.
Some of our plans have reported that as of the compliance date they have
fully implemented their implementation and they will be processing electronic
transactions. However, they are a minority. So because of the varying stages, I
think allowing the entities to work it out between themselves and determine
when are the providers going to be ready to test, when can they start
communicating that information, as long as we have the providers holding to the
May 23 compliance date, after that point the plans can say, you should have
this number by then, we expect that you will communicate it to us, and they can
continue to work together after that point.
MS. HANDELMAN: I think it is critical that we continue to do extensive
education and outreach, ongoing, continue what we are doing now as much as we
can between now and May 23.
I know all of our plans have been doing much outreach. To augment what they
have been doing, the Association worked with an NPI expert, Walter Suarez, to
develop NPI educational tool kits for large providers and also for small
providers, and that has been distributed widely. We have worked with CMS. We
know the American College of Physicians has gotten them out. We need to
continue all of those efforts.
In terms of what we need to do, to answer your question more directly, I am
not prepared to offer a direct solution today as to what we need to do to make
sure this happens.
One thing is looking towards CMS and the Medicare program to take a lead,
whether it is somehow looking for incentives, or on the flip side if there are
disincentives, for those who have not reached significant and prolonged
non-compliance, to bring them on board. Those kind of options need to be looked
at, but we are not prepared to get into what they need to be at this point.
MR. REYNOLDS: The other question that we asked everyone is, is there any
reason that any of you feel that providers should not be able to have their
numbers by May 23? Just them having their numbers.
MS. LUKE: We recognize that there needs to be more provider education and
outreach. But no, we think that providers should be held to that compliance
PARTICIPANT: We believe that is sustainable, that everybody should be able
to get their number. We also believe that it should be reported.
MS. CARTER: Based on what I personally know, I don’t see any reason why
providers shouldn’t be able to get their number. There has been an awful lot of
outreach. In fact, we went out with another update today, that went out on all
the listserves, talking to providers. I’m not sure we are getting to everybody.
MR. REYNOLDS: Second question. Is there any reason that payors shouldn’t be
able to be ready to test May 23?
MS. LUKE: I can say, Harry, that generally we expect that most health
insurance plans will be ready to test by May 23. However, because some of the
plans have not progressed in their implementation programs to the point that
they expect, I can’t say that for one hundred percent of them they will be able
to test on that date.
MR. REYNOLDS: Can you give me any kind of a —
MS. LUKE: In summary, I think the majority of plans will be able to test
transactions by that date.
MS. HANDELMAN: We also believe that plans would have the ability, most
plans have the ability now to test. But of course, the testing relies upon them
MR. REYNOLDS: I understand. I am talking about — in other words, as we
have tried to position this, this is a regulation that was set for May 23. If
we discuss any kind of a transition, there has to be something. Nobody has
given us a clear direction after May, but we have got to start putting some
stakes in the ground. We are just verifying what we have heard today about
peoples’ capability to be where they can be May 23, and whether there are any
We have heard plenty of discussion about NPPES as far as crosswalks after
that. We have heard testing these issues, we have heard other things as issues.
But to get those three groups, and I would ask the same thing about
clearinghouses, and they have already answered that they could do it.
So covered entities under the definition, which is what we all have to deal
with, are covered entities, and there are others that are not covered entities
that the jurisdiction is not quite as strong over, I am just trying to
understand the context of where everyone is, and whether or not there are
roadblocks to get to that point by May 23. We understand clearly from all day
the roadblocks after that point and the coordination that has to go on after
that point. So that is what I was trying to get to.
Jeff, I will turn the questioning over to you.
MR. BLAIR: Harry asked two questions. The question that I have is a third
question in the middle. This is for clarification. So I am going to repeat the
two questions just to make sure that the answers on those two are clear, and
then I will ask the one that is in the middle.
I think the first question was whether there was any reason why all
providers should not be able to get their NPI by May 23. I think I heard the
answer that there is nothing preventing all providers from receiving their NPI
by May 23. Did I hear that correctly?
MS. LUKE: For AHIP, Jeff, yes.
MR. BLAIR: Then the second question that Harry asked was whether the payors
would be capable by May 23 of receiving claims with NPIs and processing them,
is that correct?
MS. LUKE: I think what Harry asked is whether they would be ready to test.
MR. BLAIR: Ready to test.
MS. LUKE: So when you say would they be ready to receive claims and process
them, that is a different question.
MR. BLAIR: Receive claims and test. Begin testing.
MS. LUKE: Begin testing, AHIP’s position is, for a majority of plans, yes.
I’m just not comfortable saying a hundred percent of our members would be in
that position, because they have reported that there have been delays in their
implementation plans. So I just don’t feel prepared to say yes with certainty,
one hundred of our plans would be able to do that. The majority of them, yes,
MR. REYNOLDS: Before you go on, however there is nothing in the industry,
it may be an individual entity’s issue, there is nothing in the industry that
would hold somebody back as a payor to be able to start testing in May. Their
schedule may, the amount of effort they put into it may, but there is nothing
We know that as we go to the next step, we heard a lot about NPPES and this
and that, but I am talking about getting to May, there is nothing out there
that has been a roadblock to people, other than their internal schedules or
other things that would decide whether or not people were there in May, that
relate to NPI, not other things.
I know you may not want to answer that, but —
MS. LUKE: Harry, if I could respond, the thing that I would say is that
when the plans developed their NPI implementation plans, they allotted certain
time frames and they expected certain things to take place. And because some of
those things have not taken place, when they reassess their implementation
plans on an ongoing basis, they are now saying, we are doing our best. But I
can’t say for sure that one hundred percent of the companies because of these
other issues that have affected the implementation process would be able to
test at that point.
MR. BLAIR: Let me try to ask my middle question here. If everyone could
receive their NPI by May 23, is there anything preventing the providers from
informing the payors of their NPIs by May 23?
MS. LUKE: Yes. For AHIP I would say yes, because unless the data
dissemination policy is released and it is explained to providers how they
should use and share their NPI, I think we are going to continue to have issues
about providers being reluctant to give that information to health plans,
unless they are sending an actual electronic transaction.
MR. BLAIR: I just want to clarify what you said there. Tell me again what
would prevent them informing the payors?
MS. LUKE: What I am saying is, if a provider receives their NPI but they
still have this mistaken understanding that they need to protect it and not
share it with the health plans because the data dissemination policy has not
come out, I think that would continue to be a problem for the provider
MR. BLAIR: So the data dissemination policy, you are referring to the
MS. LUKE: Yes.
MR. REYNOLDS: There are two things. There is a data dissemination policy
and there is the database NPPES, right, Karen?
MS. TRUDEL: That is correct. There is the data dissemination notice, and
then there is the actual dissemination of the data itself. But the data
dissemination notice only speaks to dissemination from the NPPES database in
There are already requirements in the regulation that tell providers that
they have to share the NPI with a plan or another provider who needs it in
order to conduct a compliant transaction. I believe we already have an FAQ to
MR. REYNOLDS: Bill, you had a comment?
PARTICIPANT: We don’t see any mechanical reasons why that would be
prevented, and we don’t see any reason why that can’t happen. Our plans feel
that that is something that is doable and there are no barriers to doing it.
MR. REYNOLDS: Jeff, any other questions?
MR. BLAIR: I think I have those three questions as affirmative answers, as
far as we go. Until we get up to the issues of testing and crosswalks, I think
those three questions, the answer was yes.
MR. REYNOLDS: Marjorie, you seem to have a followup.
MS. GREENBERG: I was just trying to understand if the plans needed the data
dissemination policy to be published for their testing, if those weren’t
related to each other.
MS. LUKE: For AHIP, some of our plans have reported that they are
progressing with their implementation plans and that they will not need the
data dissemination policy regardless of when it is released. They are going to
proceed as they are operating today. I don’t believe that it would delay
testing in any event.
MS. HANDELMAN: I would agree. I don’t think our plans need that. It may
help them verify and validate the number and speed the process along, but it is
not a necessity. They are operating and doing without it at this point.
DR. COHN: I think my point was more clarification. A lot of what we are
talking about can happen very well without the NPPES. However, a lot can happen
in terms of testing and all of this, but there are always going to be providers
that don’t have contracts with the payors that the payor doesn’t know about.
For that you need a larger database to be able to identify who that person is,
or else you are not able to deal with the claim.
DR. STEINDEL: In the earlier sessions, one of the major points that a lot
of the testifiers gave was a barrier for them fully implementing the NPI was
lack of a prescriber or a referring physician NPI, that that was preventing
some of the process.
As I recall, some of those testifiers noted that this was only a hard
Medicare requirement and not a hard requirement from a lot of the private
plans. We have two private plans here and one Medicare plan, and I think the
two specifics I have of the questions in the private plan is, am I correct in
my statement, and have you seen anything regarding that with your
implementation? And from Medicare, when you were talking about the use of the
NPI in your current claims, have you looked at the referring physician or
prescriber field and seen that it is correctly filled out and how much of it is
correctly filled out?
MS. LUKE: Steve, from AHIP, I have not heard that concern from our plans.
We have told them that after we testified today, we were going to continue to
identify issues and submit those to CMS for additional clarification. So I can
certainly take it back and see if that is something. I don’t know if Justine
has any insight on that.
PARTICIPANT: Blues work with PBMs for their pharmacy business in a lot of
cases. In some cases plans have their own PBMs. To the extent that they are a
PBM, they would have the same issues. If a prescriber NPI is required, they are
going to ask for it and they are going to require it just like any other
transaction. But we don’t have any unique problems in that area that you
haven’t already heard, I don’t think.
MR. REYNOLDS: I think Steve’s question though is, on regular claims, forget
the pharmacy for a minute, on regular claims are there referring physician or
the referral ID issues in the HIPAA implementation?
PARTICIPANT: There are issues there, because you have people that are not
covered entities that are providers, that aren’t required to give an NPI. If
they are a referring physician and they don’t have an NPI, then there is some
talk in the industry about using secondary IDs to be able to identify who those
There are issues in the industry. I don’t know that I can express them all
myself, but I know there are concerns. These are the types of things, when you
get into testing and you start processing, the more of these things that can
come out and get resolved now, that is what we really need to be doing.
MS. CARTER: For purposes of Medicare, yes, we have a requirement that you
submit an NPI for referring and ordering. I do not have information to show
whether or not our matching rate or reject rate is different for that field, as
opposed to the other fields.
I would like to make a point about testing, though. I think there are two
ways to test, at least from the way I am looking at it from Medicare’s
perspective. One way is testing the claims process itself and all the fields
that have to be changed, and all the mappings that have to be done, and looking
at the NPI fields instead, or looking at both. I believe that work can be done,
and you don’t necessarily need a crosswalk to do that, and you don’t need
individual NPIs to do that.
But there is a piece of testing that has to be done with the actual
crosswalk itself. So if a payor is planning to use a crosswalk, as opposed to
just use the NPI to process a claim, which is what Medicare is doing, then
there has to be some amount of testing with that crosswalk file to determine
not whether your claims process works right, but for those providers, whether
or not you have got the right match.
I believe that is the piece that people need either the data from all of
their individual provides to build that, or they need it from some other
MR. REYNOLDS: That is what we had right after May 23, depending on what we
are hearing today. So up until then, people can test internally, they can do
whatever they do, but if everybody had their numbers on May 23, you could start
that testing. Again, a lot of people are implementing it and starting it now.
MS. CARTER: Although it does beg the question, if there is a requirement
that you must have your number by May 23, and then we are going to start
testing, then is there a requirement that everybody use it and every single
claim come in with an NPI as of that date because that is the test. It is
difficult to test except in production for this scenario.
MR. REYNOLDS: This is our challenge that we didn’t have an opportunity to
be a part of all day.
DR. FITZMAURICE: While we are waiting for a data dissemination notice and
access to the NPPES, I am hearing that it is possible to test with other data
dissemination notice and access to the NPPES. However, doing it with NPPES and
a notice is much more efficient and practical. It would reduce rejected claims
due to confusion over having the right number and improve validity of testing
results. You have a bigger universe of numbers with which to work.
So my question is, has the CMS administrator approved the draft
MS. CARTER: I’m not going to answer any questions about the dissemination
notice. I didn’t come here prepared to talk on that.
DR. FITZMAURICE: I just wondered whether it is a matter of public record
whether it has been approved or not. If it is not a matter of public record —
MS. CARTER: I don’t know. I’m not sure what is a matter of public record.
That is an area — I don’t work in that area of CMS. I know there has been a
lot of discussion about it, but exactly where it is in the process, I don’t
DR. FITZMAURICE: That was my question, where is it in the process. But I
accept your answer.
MR. REYNOLDS: Any other questions from anyone?
MR. BLAIR: I wanted to go back to some of the questions that I think we
understand, because I am a little nervous about having NCVHS come up with
recommendation language and then find out later that we didn’t have it fully
clarified. So please forgive me while I repeat this to make sure that my
understanding is accurate.
From what I think I have heard, there is nothing preventing all providers
from receiving their NPI number by May 23. That is number one. Number two,
there is nothing preventing all providers from informing their payors of their
NPI number by May 23. Then the third thing is, there is nothing preventing the
payors from beginning, starting the testing process with those NPI numbers by
Is there any part of that that is inaccurate or that needs to be qualified?
MS. HANDELMAN: Blue Cross Blue Shield would agree that that is accurate,
what you just said.
MS. LUKE: The only point of clarification that I want to make is on your
question two about the providers reporting. Our plans have reported that some
of the providers are reluctant to share their NPI because they think it has to
I appreciate Karen’s response that there is information out there informing
providers that it should be. So whether there needs to be additional education
of providers about sharing their NPIs, I would just like to say that that is
something we would encourage so that providers don’t continue to hold on to it
and think they don’t.
MR. REYNOLDS: But if Karen is right, which I have not found her to be not
right often, then obviously any outreach that would need to go on between now
and May 23, that is something that — you don’t have to add a system, you don’t
have to add anything else; you are just clarifying peoples’ understanding that
that would need to happen, and then they would be able to share.
MS. LUKE: That’s correct.
MR. REYNOLDS: In other words, there is no mechanical work, there is no
systems work, there is no other things that have to go on once that is
clarified to them. That is what we are trying to get to. We are trying to
understand real versus perceived roadblocks, real versus perceived schedules,
and so on. That is what we are trying to understand as we take a look at this.
DR. WARREN: Based on your clarification, Harry, I am getting a little
confused. We have heard from several testifiers that they are waiting for the
dissemination guidance from CMS before they can finish implementation. If the
fact that within the regulation it says that they have to share, what else in
the dissemination policy are people waiting for before they can implement?
MS. LUKE: In the health insurance sense, we are waiting for the
dissemination policy to explain whether they are going to be allowed access to
the NPPES system or whether they would be able to receive extract files. That
would help them in the implementation process. Those are the two primary
PARTICIPANT: We think we might have a more efficient system if we were able
to access that file and automate our processes, rather than do things manually.
MS. CARTER: The referring and ordering would be an issue there, because
even though you might get an NPI from every one of your participating
providers, there is still the matter of individual claims.
MR. REYNOLDS: Right, understood. But again, it is the mechanics of getting
an individual number.
Any other questions or comments from this group?
MR. BLAIR: I would appreciate whatever help you can give us on the next
phase. Once testing begins, we have had recommendations from many of the
providers, from WEDI, from others, that the deadline be extended 12 months. We
have heard from some testifiers it be extended six months. We have heard from
one testifier that it shouldn’t be extended. There is an array there.
The area where I am going to ask for help here is that I don’t look at the
deadlines and recommendations for NPI compliance in isolation with the other
interoperability standards that we are going to be looking at during the next
three to four years and beyond.
We have already had a situation with other HIPAA regulations where we have
had to extend deadlines, and we have already had at least one person candid
enough to tell us that there are providers that don’t believe this is going to
happen, and others that are waiting to see if it will happen.
So if we wind up saying there is more time for testing, how do we do that
in a manner that if the testing is not complete in three months, six months, 12
months, whatever we decide, how do we do that in a manner where the industry
takes us seriously? Not just for NPI, but starts to take us seriously so that
the next time we have a standard that has to be complied with, the industry
takes us seriously from the beginning of the announcement?
MR. REYNOLDS: Takes the regulation seriously. It is not NCVHS.
MR. BLAIR: Thank you, yes. Thank you for the correction. Any guidance, any
suggestions that you have would be appreciated.
MS. LUKE: My reaction to that would be that our members have taken the
regulation seriously, has been putting the best foot forward for this. But
there have been a number of things outside their control that have impacted the
What we are asking for, we think, is not a hard fast deadline. We are
asking for a reasonable solution for business reasons. I think at the point we
are at and what we have learned, six months is probably the best thing that you
can do, and then reassess it and see where they are at. But I think people have
taken the regulation seriously.
MR. BLAIR: I think you are completely sincere when you tell me that. But
just the fact that you wound up saying, then we will reassess it opens the door
that other people might look at. I’m not saying that it is not reasonable to do
reassessments. I am just trying to try to figure out a process that is fair to
everybody, that is reasonable, that is realistic, but that people will take
seriously, that a deadline is a deadline.
MS. HANDELMAN: I would just add, as we mentioned earlier, when we look at
the NPI, when we look at all of the HIPAA requirements that have come out to
date, this is probably the simplest. Not to say it is simple, but the simplest.
We probably are going to have many more that are going to be much more
complicated than this.
I think it is for that reason that we think it is important to go back,
step back and look at this and maybe other past transactions and code sets,
what happened, what can we do better.
We know for example that vendors that are not covered entities, their needs
may inject additional time requirements. Maybe those need to be considered up
front, because often we know their products and services are important to the
providers. I think what is important here is to do a thorough analysis and look
at what has happened and how we can go better forward.
While we haven’t thought through all of these issues, we do think CMS may
be a point that maybe can use some of their muscle or power, whether it is
incentives or on the flip side, to try and make something happen. Much more
work and analysis would have to happen in this area.
MR. BLAIR: Thank you.
Agenda Item: Proposal Presentation
MR. REYNOLDS: I’d like to thank this panel very much, we appreciate it. We
will move immediately into our next panel, which is a proposal presentation by
Are both of you testifying? Patrice, okay.
MS. KUPPE: Good afternoon. Thank you for having us an opportunity to
provide information on NPI to the subcommittee. I am Patrice Kuppe, Director of
Administrative Simplification for Alina. Alina is a large provider, and I will
have to remember as I am providing answers to tell you if I am wearing a WEDI
hat or a provider who is in the field implementing. I was once a small provider
with a small clinic in a rural setting also, so I can wear that hat, too.
Alina also is a provider who has been very proactive in implementing HIPAA
transactions, so we are under the gun of unhooking every transaction that we
have had in place over the last couple of years and having to redo it for NPI.
A point that WEDI makes later in the testimony and I would like to make now
is that we have talked a lot about a claim today, a little about a remit, but
we haven’t talked about the other transactions that are actually implemented
through either web based or true EDI that also fall under the requirement.
On two previous occasions WEDI had made advisements on what needs to occur
so that industry can meet the compliance deadline without impacting the health
care industry, including most importantly patients and providers and health
plans. I am glad to say that with the recent survey, we have seen an increase
in the number of individual and organization providers that have attained NPIs.
But I am also sorry to say that the industry will still not be ready to meet
the May 23, 2007 deadline.
Even though many providers have their NPI, they are still in the process of
communicating these to health plans, waiting for their billing system vendors,
clearinghouses and/or their health plans to indicate that they are ready to
WEDI’s recent discussions in November with over 200 health care industry
experts indicates that the industry is still in very early stages of
implementation. The lack of the dissemination notice and procedures and system
has severely slowed the industry’s progress.
The industry as a whole I believe has underestimated the complexity and
level of work required to implement this national standard. I think when we
first said two years was enough, we maybe didn’t take a step back far enough to
see what we were about to unhook. We are undoing years of identifier assignment
that are built around provider and health plan contracts or around system,
programming and logic. We are changing and sometimes increasing the burden on
provider enrollment in addition to the claims process. This is the case for
Medicare, which now requires the actual NPPES notice to be attached to your
WEDI presented our May survey findings at your last meeting, and we would
now like to share survey results from our NPI readiness survey, conducted in
October 2006. I am only going to be able to give you highlights today. We are
about three days away from the full report, and we will be happy to share that,
but today it will be at a more high level. Gail does have details that we can
pull from as you ask specific questions.
Unfortunately, the survey results indicate that the health care industry is
not currently positioned to meet the May 23 deadline. It is important to note
that these statistics are coming from some of the most informed providers,
vendors, clearinghouses and health plans in the nation. We believe if these
organizations are behind in their plans, then the rest of the industry may even
be further behind.
I would also like to explain that since we did not perform this as a blind
survey, we may have some organizations answering that they will be ready even
when they really won’t be. As the person who filled it out for Alina, when they
said will you be ready by May, I just said yes, I hope I will be ready, but I
didn’t say no; my name was attached to it.
Some of the highlights. This is from October, so some of this could have
changed in the last few months. Only 50 percent of the providers who responded
had their type one NPIs, and only 39 percent have their type two or their
I need to confer with Gail. We had 480 respondents total? We had 700 total
respondents from all provider-health plan-vendor categories.
Over 50 percent of the providers indicated they will not be ready to use
NPI on claims and remittances until after April 1. So that would preclude that
we could start testing maybe April. That is for only 50 percent.
Sixty-five percent of the payors will not be ready to use NPI on claims and
remittances until after April. So we had a few more payors that will be ready
to test in April than providers. Testing as you have heard is important in
order to validate that providers will be paid the same on the NPI as they are
in legacy today.
As of the survey, 75 percent of billing system vendors are not ready for
the NPI. So as of October, 75 percent of those people still weren’t ready,
which means that providers do not have the software available to start the
testing and implementation process.
Approximately 20 percent of the clearinghouses will not be ready to process
NPI by March 2007. In addition, 59 percent of clearinghouses indicated they
will need anywhere from six to 20 months for trading partner migration
Again, it is important to note that these findings are about just two
transactions, the claim and remittance advice.
MR. REYNOLDS: Can I ask you a question before you go on? Six to 20 months;
can you tell me what the question was? If you had blocks like six to 20 and
never and stuff like that, six to 20 might be all right.
MS. KUPPE: We did. Do you want me to keep going while she looks it up?
MR. REYNOLDS: That would be great.
MS. KUPPE: We don’t know what the impact will be if we have to stop using
these due to noncompliance. I am talking about the other transactions.
Eligibility is the start of the data food chain. If I have to turn it off, it
means I have bad data in claims. Claims status is another one that is just as
important. A common issue affecting both providers and health plans is the lack
of a data dissemination system. Without an easy lookup to providers who are
ready with their own NPIs, are still at risk because they will not be able to
create a compliant claim. You heard that all day long. That is the referring,
This is because many providers don’t have an understanding about how and to
whom they should share their NPI even if they have one. Without an online
lookup like we had for UPINs, providers are not able to share their NPIs in an
I like to provide real-life examples. I have tried to lock down doors at
Alina. You don’t get hired without one, you don’t get privileges at the
hospital without one, you don’t get to refer patients for physical therapy
without one. I’m not able to totally lock those doors down.
An example might be, a hospital receives a call from a clinic referring a
patient for lab work. The hospital scheduler tells the clinic scheduler, I need
your referring provider’s NPI. The clinic doesn’t know what we are talking
about. In the past process, the hospital would ask for the UPIN. If unknown,
then we might take a minute and go try to look up the UPIN on a website. Under
this scenario with NPI requirements, a claim could not be submitted.
Labs and pharmacies are facing similar problems, but are even more removed,
since the patient and/or provider are not part of the business flow at all. If
a pharmacy is required to submit the NPI of a prescriber, without a formal
business relationship with the prescriber, providers are unaware of the
pharmacy’s need for NPIs.
The absence of the data dissemination system consumes valuable resources in
NPI implementation. I have heard questions today, why are we still behind. I
think because we are all trying to share numbers that we didn’t know we were
going to have to tell each other about.
Providers and plans have had to focus their efforts on collection of NPIs
among each other, since there is no dissemination system available.
One of the recommendations put forth by WEDI in a letter to HHS, based on
information at an NPI hearing in April 2006, stated that we needed to have the
NPI notice and operational dissemination system by June 15, 2006 in order to
meet the deadline. As of today, we still do not have it.
We believe this delay has caused us to change the recommendation we brought
forward to you last time. That recommendation stated that we needed a
contingency period of six months from the deadline where transactions would be
required to have the NPI, but will continue to have the legacy ID, which is
what we call dual use.
Today WEDI would recommend that HHS establish a contingency plan to allow
the use of legacy identifiers in addition to the NPI for 12 months after the
industry has access to the NPPES data.
We fought long and hard, or I could say we fought long and hard among
ourselves, on how much time the industry might need. We went back to earlier
work. We had put together a very detailed implementation plan that we asked the
industry to use as a guideline back in 2004. That is a very detailed plan,
where we outlined the steps needed for successful implementation. It has
milestones such as, you get your NPI, you share your NPI. We have a system to
look it up, we test it transaction by transaction by transaction.
I joked that we fought long and hard, because that said we needed another
18 to 24 months once we had dissemination. We agreed though among ourselves
that we will ask for 12 months, knowing it will be a challenge, but we have to
push the industry.
The third page finally gets to some of the specifics that you have been
asking for. The major milestones left to implement; we need access to the NPPES
data, and we need to have a clear understanding how the process works and what
the policy is for dissemination. We say in the testimony, 15 to 30 days to read
and understand the policy. I’d like to take this down and say what do I have to
do back at the office to figure out how does it work and what can I do now.
Then I need some time to communicate and provide training among all my 60
clinics and hospitals, et cetera.
The industry must be able to access and use that data. Sixty to 90 days to
download large files and create crosswalks, one to 30 days to train process
personnel in how to access, and then 90 to 180 days to test internally and to
test and implement with trading partners.
Testing is a word that can be used in many ways. Testing for us means all
transactions, if it is EDI, if it is web, if it is IVR. It includes testing for
both technical, is that a ten-digit number, does the check digit work, and is
it revenue compliant or accurate, do I get paid the right amount.
Clearinghouses and vendors and providers and health plans need end to end
testing. Up to 12 months will be required for the second tier testing, for
example, clearinghouses test and implement with all health plans, and again
that includes technical compliance and routing to the right partner. There is
some overlap in trading partner testing identified above, but the number of
entities involved in this phase is significant and will require additional
Finally, a significant number of health plans and clearinghouses and large
providers don’t have an adequate enough time to complete their NPI crosswalk
population and validation along with testing their claims adjudication
remittances by the deadline. This is due in principle that the NPI
implementation process involves a trickle-down effect, resulting in a
significant number of activities being done in a compressed time period.
As an industry, the following key activities are all behind schedule and
must be completed before adequate trading partner testing between providers and
payors can be accomplished. Providers must get their NPI, vendors must deliver
a fully functional NPI solution, data dissemination procedures must be
available, implementation in new paper claim forms which accommodate NPI must
be done in conjunction with elimination claims processing capabilities.
In conclusion, WEDI acknowledges there are many details and questions that
need to be addressed as part of this recommendation. WEDI is willing and able
to leverage its knowledge and industry expertise and resources to work in
partnership with CMS to address the challenges and to insure a smooth
transition to the NPI industry.
I took some notes off of the top three questions earlier. Will we be ready?
No. Why? We are undoing years of logic. The recommendation for NPI came out in
’05 through the WEDI report, and here we are. That many years have gone by
where we built up these proprietary systems.
This is a large project requiring major milestones to be met along the way.
Provider enumeration may have been delayed because some of us larger providers
are waiting for a way to bulk enumerate.
I am speaking as Alina now. I was thinking about May 2005 when the system
came up. I am ready to go. I knew who I had to enumerate. But I have 1500
providers. I waited and waited. Finally in January of last year I said I am not
going to wait. I went online, or hired some people, and did 1500 of them one by
one, just so we would be ready. So we have all the numbers for our type ones
and type twos, but that slowed down our whole plan because we didn’t get step
one done when we thought we were going to.
Dissemination was a factor. I think you have heard over and over, we still
need increased education. I am all for a 30-second Superbowl ad, something that
will get everybody’s attention. If we can do those things, then we can test, go
to the dual use, get to NPI only, and then we can move past claims and remits
because we still have those other transactions.
Just to summarize again what do we need to do, we need to work off a
detailed plan. We need the one year contingency so we can work together to put
together a very explicit milestone step by step plan. As WEDI is recommending,
we are asking for NPI plus legacy as of May 23.
Then as others have said, we need to learn from this for future
regulations. Sometimes just saying we are going to be done in two years might
not be the answer until we start getting into it phase by phase. WEDI will be
happy to hep with that future learning discussion.
Gail, did you have that info?
MS. KOCHER: Jeff, to your question about that particular — how much time
the trading partners needed for the migration, the buckets were less than six
months, six to 12 months, 12 to 18 months and then more than 18 months. Do you
want the percentages?
MR. REYNOLDS: So everybody is grouped in six to 20, is what you are saying?
MS. KOCHER: Twenty-eight percent said less than six, 39 percent said six to
12, 12 to 18 months was 22 percent, and 11 percent said more than 18 months.
MR. REYNOLDS: Patrice, you made a statement that NPI plus legacy as of May
23. What does that mean? I know what I think it means. Is that saying —
MS. KUPPE: WEDI approved the message of NPI plus legacy a couple of months
ago. We were further discussing this yesterday at our board meeting. WEDI’s
official recommendation today is dual use, meaning all providers would have an
NPI in there plus their legacy ID. We would allow both. But when we talk about
ordering, referring and prescribing, WEDI didn’t come to a decision yet on what
it meant about those particular items.
MR. REYNOLDS: Let me drill down a little further. When you add plus, you
are changing the game. Dual use says one NPI or legacy or both. A lot of people
have implemented dual use. So you are saying that as of May 23 people can’t
send in the old number?
MS. KUPPE: Correct.
MR. REYNOLDS: They have to send in the new NPI and the old number.
MS. KUPPE: Correct.
MR. REYNOLDS: Both have to be there or the claim should be rejected, that
is WEDI’s recommendation, which goes back to our earlier discussion where we
said providers would have to have their number, they would have to share it and
people would have to be ready to process it.
So you are saying differently than what I think we heard before. At least,
I recollected that we heard before. You were saying that as of May 23, NPI is
the only requirement.
MS. KUPPE: That is WEDI’s recommendation.
MR. REYNOLDS: That is a different recommendation than we heard before.
DR. COHN: I just wanted to also clarify. The survey that you did appears to
be primarily focused on the testing process, as best I can tell, or at least
that phase of it. Did you get any comments from any provider members of WEDI
that indicated their readiness to have systems that could submit the NPI?
We heard earlier today that there seemed to be some issue that at least
some providers were having that this recommendation might preclude.
MS. KUPPE: The survey did talk about all transactions, and they asked the
same questions of providers, vendors, clearinghouses and health plans. The
actual billing system vendors did say 75 percent of them in October were not
ready. So the vendors responded that way back in October. I do recall, I think
there is a provider question that way.
MS. KOCHER: This survey, some of them had 70 questions per group, so it
takes longer to find.
DR. COHN: I think the reason I was asking was, we are all talking about
different levels of what this might look at. It is one thing to say a provider
can have a number by a date. I was just trying to figure out if there was an
issue with physically getting that new number and whether there were any
Your recommendation assumes they will be able to get it to the plan, much
less the plan be able to deal with both of them. So that was the question.
MR. REYNOLDS: The clearinghouse or anyone else.
DR. COHN: The clearinghouse or anybody else. It sounds like you are saying
that 75 percent of the —
MS. KUPPE: Billing vendors, the practice management and the information
systems, the lab.
DR. COHN: Will be able to do it.
MS. KUPPE: Were not able as of October. Alina, big provider, our vendor
implemented the solution early this year. It is already loaded. Now we are
ready to go.
One caveat with my Alina hat on, if I am allowed to split my information,
is even with WEDI’s recommendation, I still am going to have an issue as was
mentioned earlier with the referring, ordering, prescribing. I don’t own those
numbers. I am ready to go with anything I have to report on a claim.
MR. REYNOLDS: Steve, I’m going to let you have your comment, and then I
have got to follow up on what you just said. It has been a long day. Help me
remember what you just said. Steve, your turn.
DR. STEINDEL: Thank you, Harry, and thank you for throwing me off track.
What we have heard during the day, and particularly in the last panel, that
NPPES was really not the be-all end-all in solving the problem of looking up
NPIs and resolving those issues. We heard from Medicare just a few minutes ago,
who of all the people is the only one that has access to NPPES. We heard Cathy
state fairly clearly, yes, it was helpful but it didn’t provide all the
answers. We heard from Blue Cross Blue Shield that they are willing to go with
a hard date of May 23 even without access to NPPES.
From what I have heard, we have had some mixed statements about the access
to NPPES and how helpful it would be. It may clear up fairly easily the
rendering, referring prescriber field, where you have the person who is
submitting the claim and then you have this other field that is wide open. It
may help in that area.
But my question is, you just stated that you were asking for, as of May 23,
both IDs. Why do you need NPPES? Why can’t we recommend — if you say go with
both IDs, we realize it is going to take some time to assemble crosswalks and
clean things up a little bit. Why can’t we say yes, let’s go with both IDs and
six months later kill the legacy?
MS. KUPPE: WEDI’s recommendation is totally in agreement with your first
thing. Yes, let’s go with both. But we did say 12 months because of the amount
I am one provider. I have 14 health plans I contract with. I want to test
everyone to see if they crosswalked me right.
DR. STEINDEL: So WEDI’s recommendation has no presumption on availability
of NPPES? I thought it did.
MS. KUPPE: No, I’m sorry, it does.
DR. STEINDEL: What I am saying is that if you are getting both numbers
already, how is access to NPPES going to help you?
MS. KUPPE: We hope it is solving the ordering, referring, prescribing. And
payors are wanting to pre-build crosswalks, some, not all; some are wanting to
do it off a claim. But some part of our community is pre-building the
crosswalk. I believe that is what they are hoping the system helps them do.
DR. STEINDEL: To both of those points, if we implement your recommendation
requiring dual IDs, what that is saying to me is, we are requiring the dual ID
also in the referring, rendering, prescriber area as well.
I am pulling six months out of my head, primarily because I am assuming in
the six month period that the system — and that means everybody in the system,
the clearinghouses, the payors, pharmacies, et cetera, in that period they will
probably see all NPIs that they are dealing with today. They have now both. Why
can’t they use that information to build their crosswalks, and then six months
later start using them?
MS. KOCHER: Steve, with my health plan hat on, we have been taking in NPIs
from the claims for about — I guess at this point it is about ten months, 11
months. What they found is, it still required a awful lot of manual review, a
lot of verification back to the providers. The providers may not have entered
their data correctly into their systems. So it still ended up being a highly
As a health plan, I still need to verify that the provider number that I am
ultimately going to use belongs to the provider that I think is telling me it
belongs to, and that that is the provider that I am going to pay and that is
the provider that truly should be paid. So it is that credentialing
verification process, which just taking it in on a claims transaction still
requires manual resources to verify that it is really what it is intended to
DR. STEINDEL: Can I paraphrase what you just said, and tell me if I’m
correct? What you would require access to for NPPES is for validation of the
NPI and it would be easier if you had access to it. If you do not have access
to it or if it doesn’t match, then you would have to invoke the manual check.
MS. KOCHER: I agree with that, but then it also would be our hope to
capture any of the providers that were having difficulty in either getting them
because they don’t realize they need to send them to us. It is not just
verifying the ones, it is also an attempt to capture the ones that we don’t
have. The manual process is reaching out to providers, a provider having to
mail 18 pieces of paper to 18 payors, it reduces the burden on the provider
DR. STEINDEL: I thank you for clarifying that area, because that was my big
question. I was confused about why we needed to continue to have access to
NPPES. Thank you.
MR. REYNOLDS: Patrice, back to my question that I had for you. So WEDI is
prepared as of May 23, having heard the testimony all day, where there will be
a few, being ten to 20 percent, or a significant, up to 40 percent, of people
that may or may not have their number. And with the rendering issue that you
talked about, which will be built by getting both numbers in many cases. WEDI
is recommending that those claims be denied, be rejected as of May 23.
MR. GUBEL: (Comments off mike.)
MS. KUPPE: That is Mike Gubel from the WEDI board, who they had said was
also going to be calling in. He was at the board meeting all day yesterday, so
he might have more new information.
MR. REYNOLDS: Did you have a comment on this, Mike?
MS. KUPPE: WEDI said once we have access to NPPES, we believe it is 12
months, to then do the rest of the steps. They refer to page three. I think
Steve was right, he was like that six month testing, but if you look at the
first two steps, that is your other six months. It says we believe as an
industry we will be ready.
MR. REYNOLDS: I’m not talking about your 12 months.
MS. KUPPE: We do not talk within WEDI about, will a payor reject a claim or
MR. REYNOLDS: But your exact recommendation is, as of May 23 every claim
must have both numbers?
MS. KUPPE: Correct.
MR. REYNOLDS: That’s fine. No, she is not going there. Mike, I’m not
disagreeing, I’m making sure we hear what she says. That is what she says. As
of May 23, every claim must have both numbers, period.
MR. GUBEL: Mike Gubel on the line from WEDI.
MR. REYNOLDS: Mike, do you want to make any comment on that?
MR. GUBEL: We are suggesting in our recommendation that there be a
requirement that we have a contingency plan of a dual ID. I think part of the
problem we are having right now, Harry, is that there are a lot of different
interpretations of what will happen on May 23 with the dual ID. I think there
are some organizations that are thinking about either pending claims or
rejecting claims. I don’t think right now it is our position — the question
is, are you going to reject it because of an NPI. I think it hasn’t been
resolved as an industry yet.
I’m not going to propose a solution here, but we have to ask ourselves, are
we going to reject the claim because it is not an NPI client or is it not an
NPI that exists in NPPES, or is it something that a payor doesn’t have in a
crosswalk. There are all different layers and levels of editing here that I
don’t think we have worked out in entirety.
MR. REYNOLDS: But the statement is still that both numbers have to be on
MR. GUBEL: Yes.
MR. REYNOLDS: I’m just making sure that that is the official position. I’m
not going to ask you what you are going to do with it, but that is the
statement. Mike, do you have anything else to add to that?
MR. GUBEL: I’m going to have to dial back in. I’m getting a lot of static
MR. REYNOLDS: Jeff, go ahead with your question.
MR. BLAIR: One of the ways that I want to clarify this next piece which I
have heard is to give two examples which test the extremes in order to
determine whether we really have agreement on the statement. The statement that
I have heard is that the WEDI recommendation is that once the NPPES is
available, that there should be 12 months for testing.
So here are the two examples I want to give to know if that statement still
applies. If NPPES is not available until July of 2007, do we still need 12
months for testing? That is one example. The other example is, if NPPES becomes
available February 1 of this year, just a few weeks from now, does the clock
start ticking then for 12 months to be finished with testing?
So that is my question. If the answer is yes to both, then I think we are
in lock sync with what is meant by 12 months until testing is finished.
MS. KUPPE: And Harry, I think I was answering your question wrong, and that
is why we were getting the — WEDI would hope that we are in various phases
with various trading partners today. I am testing NPI plus legacy with some of
my health plans. The specific wording was that we should establish a
contingency plan to allow the use of legacy plus NPI after we have access to
NPPES data. So in Jeff’s example, if I am reading the black and white words,
would that mean if it is ready in February, do we just go 12 months from that.
MR. BLAIR: Yes.
MS. KUPPE: I believe if I am a lawyer, I would say that is what we wrote. I
believe what WEDI was saying potentially was, if it is up running and we can
use it, then we need 12 months from that date.
MR. GUBEL: I would agree with you. It is 12 months from the time that data
would be available.
MS. KUPPE: The time that the data is available. So February 1 of this year
— all morning, I kept saying, remember to use the caveat, can we use it, is
that the right date is yet to be determined. We hope it is because we gave a
lot of recommendations over the past few years. But 12 months from the time we
can access that system, that would be our contingency extension we are asking
MR. BLAIR: The other example that I gave, if it is not available until the
end of June of this year, then the clock would start ticking at the end of June
of this year for 12 months, is that correct?
MS. KUPPE: That is. Thanks for clarifying for us.
MR. BLAIR: Thank you.
MS. KUPPE: One other caveat, by the way. All transactions don’t support
dual use, so there is a little more work when you are talking about eligibility
and claims status, I think, and NPPES.
MR. REYNOLDS: So your dual use comment was based on claims and remittances?
MS. KUPPE: But not pharmacy claims. So institutional, professional and
dental, but not pharmacy, because pharmacy does not support dual use.
MR. REYNOLDS: So help me with what that means. Is WEDI not making a
MS. KUPPE: I would say we excluded pharmacy in our recommendation. I
apologize to our pharmacy group for that. They were at the table. But I would
defer to the pharmacy experts here about the type of contingency they might
MR. REYNOLDS: Anybody in the audience want to speak from the pharmacy
group? Does anybody want to speak to that statement? Obviously there is a
pretty significant proposal on the table that draws a pretty dramatic line in
the sand. I’m fine with it, but I want to make sure we understand what is in
that line and what is outside that line, and what that line means.
MR. BLAIR: I have no problem with that piece, but I do have one other piece
of clarification when you are ready for it.
MR. REYNOLDS: Well, they are coming up, the pharmacy people. Welcome back.
MS. VILARET: Glad to be back. What as your question?
MR. REYNOLDS: The question is, WEDI is recommending that as of the time
that NPPES is ready and usable, and we will have to work on those terms, but
ready and usable, that at that point both NPI and the old number would be
required on claims transactions. Then at a 12 month period that would be
completely switched over just to the NPI.
So they are saying that they had excluded — hold on a second.
MS. GREENBERG: But then you brought up this thing, what if the system is
available by February 1. But the fact is that the regulation only requires the
provider to have it by May 1.
MR. REYNOLDS: Agreed. I still think it is May or later. May or later is
what it will probably end up, and I am just using her words. Let’s go to
MS. VILARET: First of all, pharmacy claims only allow us to submit one
MS. KUHN: There is only one data field.
MR. REYNOLDS: So compared to the 837, you only have one number in your
MS. KUHN: Right.
MS. VILARET: Exactly. So we submit either a legacy number or NPI, that’s
MS. KUHN: And it cannot accommodate health care provider taxonomy codes,
MS. VILARET: So we cannot accommodate their recommendation.
MR. REYNOLDS: But if they are saying that by May 23 or using Jeff’s
example, the end of June, that every claim would have an NPI, you should be
able to accept the NPI then. All your claims would have the NPI on it, because
everybody — by association.
MS. VILARET: We don’t have a dissemination notice. We don’t have a
prescriber listing. That is the reason that we aren’t able to submit prescriber
NPIs at this point. That is the only reason at this point, because we don’t
have a valid list of prescribers.
MR. REYNOLDS: I understand. You feel that you absolutely must have the
NPPES, because you do not have direct involvement with a lot of these
submitters, and that will be your base to get the number.
MS. VILARET: Right. While we appreciate the share it philosophy, we feel
that it is very, very important to get from a valid source. Because of the fact
that we are audited on these numbers, we must make sure that these numbers are
from a valid source, that they are accurate. The health plans come back to us,
and if we do not submit a valid number, then we are audited and claims are
MR. REYNOLDS: So the differentiation is, since the rest of the industry
would have two, they are still processing on the old number and using the new
number to build crosswalks.
MS. VILARET: Right.
MR. REYNOLDS: I understand that. In your case, whatever number that comes
in better be right in the — the prescribing better be right.
MS. VILARET: We have one chance to get it right, and that’s it.
MR. REYNOLDS: And if you haven’t seen NPPES and can’t study that and can’t
make sure that that is complete, then that puts you at a disadvantage, versus
the dual use where you have both numbers.
MS. VILARET: Right. They have a chance to submit the dual use, clean up the
file as they go. So it is a working file. We don’t have that opportunity. We
have one chance to get it right, so we need to bring the file into our system,
get it right internally, and then submit it.
MR. REYNOLDS: That is a good clarification between the two.
MS. VILARET: That is the difference. That is the disadvantage of using 5.1.
It has one field.
MR. REYNOLDS: Thank you. Very helpful.
MR. BLAIR: The previous panel, we had our payors. We appeared to come to
consensus on three points with respect to expectations for May 23, 2007. I
would like to give this panel the opportunity to comment whether you feel
comfortable with the three agreements that we came to with the previous panel,
the payors. I will repeat it.
MR. REYNOLDS: Let me mention something in the meantime. WEDI went well past
that. WEDI went way past that recommendation. So that was the base level that
we had prior to their testimony.
MR. BLAIR: Then that may be where some clarification may be helpful. What I
was hearing in our discussion during this last ten minutes with WEDI and the
rest of this panel was with respect to how much time will it take to complete
the testing. That is the 12 months. I felt like there seemed to be consensus
that was arrived at with that piece.
But it appeared to me that in the previous panel, the question was — and I
will repeat these, and if there is not agreement on these, then this will be
helpful to me to know that things unraveled between one panel and the other.
My understanding was that in the payor panel, there was agreement that
there was no reason why all of the providers could not get their NPI identified
by May 23, that they couldn’t wind up communicating that to the payors, that is
the second piece. Then the third piece is that if those two things happened,
that there was no reason why the payors couldn’t begin the testing process if
the first two of those three things occurred.
I just wanted to validate with this panel that they felt okay with that
MR. REYNOLDS: Let me say something before we go to the panel.
MR. BLAIR: Sure.
MR. REYNOLDS: We have had four or five panels answer those three questions
affirmatively, so not just the last panel. The second thing is that where
WEDI’s is different is that they are not talking about beginning the testing.
They are talking about that every claim that would come in as of that date
would have both numbers on it. That is a whole lot different than starting the
So they have upped the ante dramatically to say that it is a requirement
that every claim has both those numbers, versus the others ones have said, we
are ready to start beginning to receive these, but nobody said both had to be
there. That is the difference.
You now have brought all the vendors in, you now brought all the others.
I’m not for or against anything. I am making sure this is absolutely clear,
what we are hearing and what is being said.
MS. KOCHER: Can I just offer a point of clarification? I think what we are
seeing here is a difference in the definition of what testing is. WEDI has
included actual production style testing, where you would put both an NPI and a
legacy ID on a claim and what we define testing as.
MR. REYNOLDS: I understand.
MS. KOCHER: So depending on how you define testing, whether you are talking
pure test environment or production environment, I do believe the answers to
those questions could be different.
MR. REYNOLDS: Right, but the difference I heard earlier was, once you would
begin the testing, if the provider could get it then they could give it to
somebody. But if their vendor wasn’t going to be ready for another month, they
were not required as of May to put both numbers on there. That is the testing
we were talking about earlier today.
You basically drew a line in the sand and said, effective this date, both
numbers, here we go. So Jeff, that is the differentiation.
MR. BLAIR: Let me see if I understand the distinction that you just made.
MR. REYNOLDS: Yes, but she has got a comment on it. Go ahead, Patrice.
MS. KUPPE: Once we have access to the NPPES.
MR. REYNOLDS: Yes, we get that point. Go ahead, Jeff.
MR. BLAIR: Then let’s separate out the third of the three items that I
thought we had agreement to in our last panel. The first two, is there any
disagreement to the first two, which is, there is no reason why all providers
can’t get their NPI by May 23, and there is no reason why all provides can’t
inform their payors by May 23? Marjorie, there is not agreement to that?
MR. REYNOLDS: There is agreement.
MS. GREENBERG: There was agreement in the previous panel.
MR. BLAIR: There was agreement in the previous panel.
MS. GREENBERG: But you said there were several other panels.
MR. REYNOLDS: That agreed the same.
MR. BLAIR: Right. So I guess what I am saying here is, I want to give this
panel the opportunity —
MS. GREENBERG: All the providers agreed that they could all get their NPIs
by May 23?
MR. REYNOLDS: That there was not a physical barrier. I remember the
question clearly. There was not something needed from CMS, there was not
something needed from somebody else. Whether they are being communicated to,
whether they understand it or whether they do anything else — remember, we are
talking about the semantics of whether or not there is anything in somebody’s
way. Whether they started late, didn’t understand, that is different.
MS. GREENBERG: I thought I heard some of the providers say, but maybe I
misheard, that without the dissemination policy, the absence of that would keep
some providers from providing their NPIs, even though that may be a
misinterpretation on their part of what they are required to do.
MR. REYNOLDS: But what we said is, between now and May, if that
clarification is sent out, then they should be willing to share. That is what
we are saying.
So all of the physical roadblocks, organizational roadblocks and others
things appear to be — that is where we were going with all that.
Jeff, did you have anything else?
MR. BLAIR: I just wanted to give this panel the opportunity to see if they
agreed with the previous agreements that we have heard from the other panels
with respect that there is not an impediment to all providers getting their NPI
by May 23 and communicating those NPIs to their payors by May 23.
MS. KUPPE: WEDI doesn’t have a specific item where we discussed that. What
I will say is, I think the only panel who agreed to that was the payors. As a
provider who has worked hard at this and has a whole statewide collaborative,
personally I would think yes, providers should be able to get that number
within the next five months.
If we do, the recommendations we heard today, which is, there has got to be
more outreach to specific groups and members. Just the CMS bulletins doesn’t do
it, because everybody is not a CMS provider. A plastic surgeon refused to get
an NPI to my hospital medical staff two weeks ago. We had to sit him down one
So there is caveats, Jeff, to that agreement, but if we work hard and
focus, and maybe it requires a small group some room, which is all of these
people here putting together some concrete action plans, I think we can get
that thing done. All providers should be able to get an NPI.
We have to answer some very basic questions that we thought were coming out
in the dissemination notice. Karen alluded that it says in the law, you are
supposed to use it and share it. I have providers who say I don’t need one, I
don’t bill electronically. That is what that plastic surgeon told me. I was
lucky to inform that doctor. I said, guess what, in Minnesota we mandated it on
paper, so I was able to arm wrestle them into that.
But again, I can’t really speak on behalf of WEDI, except to say I am one
of their loudest provider members and I am on the board, and I would say, if we
do some very focused outreach and education, I would have a feeling that we
could get 90 percent of the numbers. It is the 80-20 rule. Our survey already
said we had over 50 percent of our members saying yes, they had them. I think
we heard much higher numbers earlier this morning.
Then the second question about, can we communicate to payors. Again, I will
talk as Alina. It was not in my plans to communicate to every health plan that
gets a claim by numbers. I contract with 14 health plans, and every single one
of them has a very detailed crosswalk of 150 organization NPIs to that payor’s
legacy ID. It was delivered to them in June. My 1500 individual provider
numbers have been crosswalked to those 14 health plans. But I don’t have plans
to go onto Aetna’s website and Wellpoint and every other plan that ends up
getting a claim when all you people visit us in the summer and break your leg
So I was hoping for dissemination somehow to solve that issue. So again, I
feel that I can’t speak on behalf of WEDI, Jeff, to those two things, but
hopefully my provider hat gave you some insight.
DR. CARR: I have two questions. One is, for new providers, where will they
get their legacy numbers? If you have to submit both an NPI and a legacy number
after May 23, where do you get a legacy number? That is one question.
MR. REYNOLDS: Let’s let Patrice or anybody who wants to come up answer
MS. KUPPE: A legacy number is usually assigned because you have contracted
with that health plan.
DR. CARR: Right.
MS. KUPPE: So normally you have to enroll that provider or you have to
enroll with that health plan. So if Dr. Smith starts working for me May 22,
that provider has been enrolled with that plan. They will know that there is no
legacy that I know. We know they are all going to have secret ones in the
Just like Medicare. Medicare would know that Dr. Smith does not have a
UPIN, hopefully supplying them a month earlier, something like that. Every
other plan in the nation who doesn’t contract with me was always looking for
just a UPIN or something. That gets into some of the more tricky detail.
MR. REYNOLDS: Did you have a followup to that?
DR. STEINDEL: That just contradicts what you said earlier about defining
dual use as an NPI plus a legacy. As Justine just pointed out, if a new doctor
comes on board after May 23 and the only thing they get is an NPI, and their
legacy is now quote-unquote secret, they don’t know it, that is not dual use
MS. KUPPE: It is to allow the use of legacy. I believe it would be the
provider’s purview to decide yes, I still need to send it, or the payor would
be saying they still need it.
DR. STEINDEL: So you are going to the first case that Harry mentioned in
terms of dual use, NPI or legacy or both.
MS. KUPPE: NPI always, legacy if needed.
DR. STEINDEL: Okay, that is a modification.
MR. REYNOLDS: I would say there are people in the industry right now,
providers are just ending the NPI, they are completely implemented, so the
legacy system is immaterial, the legacy number is immaterial.
Justine, you had another question?
DR. CARR: Yes. My second question was, with regard to Jeff’s question about
if everybody gets a number and everybody informs the payor of their number,
does that address the situations of referring doctors and all of that? If you
are referring in a lab test or something and it is not your payor, just getting
a number and informing the payor doesn’t guarantee that all the numbers are
available without the NPPES.
So to me, it sounds like that NPPES is critical, not just in pharmacy and
MR. REYNOLDS: They said it is a prerequisite to their recommendation. They
have said that.
MR. BLAIR: We just want to parse out in terms of what could we reasonably
say should be required as of May 23. I was trying to find out where the
dividing line was. I think I heard here that the first two of those three items
we can ask for by May 23. The third one, which got into the testing piece, that
is too ambiguous, and there are other issues there. There are a lot of
complexities on that. But I think we drove to a consensus on the first two
DR. CARR: I wasn’t clear on what is the assumption that NPPES is available,
MR. BLAIR: It is not making an assumption. It is separating that out. It is
relating the NPPES as a requirement for testing.
DR. CARR: Not for testing, for a prescription to be processed in the
moment. We just heard, I thought, that without access to NPPES, the pharmacy or
prescription folks can’t validate that they have the right NPI. So they were
saying, if you inform them, fine, they are not going to believe you until they
see it in an official source.
MR. REYNOLDS: We will have to see how this works out, but it looks like
there has got to be two distinct paths. One is for pharmacy because of the
issues they just brought up, and one is for the other claims.
DR. CARR: But I am saying, in the setting of the referring physician or the
setting of a lab test, are we assuming that those referring physicians have
informed the same payor as well? Just informing the payor, as you said, with
the water skiers or whatever, there are people in another state that might not
have informed —
MR. REYNOLDS: I think that is going to have to be part of our discussion.
We are going to have committee discussion here in a second. Karen, if you have
a comment on what Justine has said, and Steve, you had a comment. Then I want
to let this panel step down. Then we need to do some discussion about what our
approach is before we lose sight of that.
MS. TRUDEL: I wanted to suggest that in addition to looking at retail
pharmacy versus the other transactions, there is probably a need to look at
primary NPI use versus secondary NPI use.
MR. REYNOLDS: I think that is a fair statement also.
DR. STEINDEL: I’d like to hang a comment and get a response from WEDI on
this. There has been a continual presumption in all day’s discussion that NPPES
is going to be made available.
Now, the reason why I say that is because I think from day one of the
discussions of NPI, there have been continual requests from CMS to make NPPES
available. Here we are, 119 days before implementation, and we have still no
indication from CMS when this will be made available.
Now, I know that CMS is working very hard on making this available, but
what are we going to do if somehow this still is in the bureaucratic holes a
year from now? You are asking that it be a year after it is released before we
put it into play.
MS. KUPPE: I would say this industry would unfortunately expend a lot of
money and resources unnecessarily sharing numbers one by one and calling each
other up and building databases one by one, instead of looking to a central
system. We would be expending a lot of money and resources, I believe,
We saw the proposal in the first NPI NRPM in ’98, so we know that they are
thinking about it. We gave a lot of input and then in the final thing they
talked about what kinds of data. So we built plans and testing and scenarios
and milestones around the concept that yay, there is a national place where we
can get at the data.
Specifically if that is not ready for a year, we will probably be here in a
year wasting a lot of money saying we still need it. Dr. Smith is going to
graduate in 2020, and somehow everybody is going to have to know Dr. Smith’s
DR. COHN: I think I want to respond to Steve. I think we have heard a lot
of evidence today that the system will not work unless there is a central
database, in the same way that you can’t do UPIN without a database and
numbers, or DEA without a database and numbers. There needs to be some way when
you don’t know what is going on, or if you are a pharmacy and you do know what
is going on, to get it.
DR. STEINDEL: Actually that is the point that I wanted clarified, that we
cannot make the system work effectively without the access to a central
authoritative database of the numbers. Your clarification, Simon, is directly
aligned with what WEDI just said.
DR. FITZMAURICE: I was going to comment on what Steve commented. I think we
also heard just now that if it is not made available, the industry will go
ahead and spend resources to create a national database that may not be as
authoritative as the one that exists inside the government, but it is necessary
to make the system work.
MR. REYNOLDS: But I think the problem that that creates is, CMS does not
stand alone. Many CMS claims go to other people. So if you start having
multiple sources of the truth, and you start crossing claims over from CMS to
payors and payors to CMS, you will absolutely guarantee chaos. It just depends
on how fast it occurs. There are a lot of heads nodding in the audience when I
make that statement.
DR. STEINDEL: And Mike, I think we have also created an unfair playing
field because we heard that Medicare does have access to NPPES.
MR. REYNOLDS: Thank you, ladies, very much. Before we start our
deliberation, I would like to make sure that the audience understands one
thing. Many of the questions that we have driven and many of the statements we
have made were to drive to some kind of understanding, not necessarily all of
our positions on what is going out as far as a letter or anything else.
We have a responsibility as we are going through the hearing to adjudicate
it. Now we have a responsibility to step back from the adjudication of it and
turn this into a discussion about what do we recommend to the Secretary. So we
have that right to change that position now.
We needed to drive to a clear understanding in this hearing today. So we
pushed some buttons today that we may not believe, just to make sure we
understood. So as we step back as a committee, I ask you to make sure that we
now step back into another realm where we are going to recommend what we are
going to do next. That is going to take all the stuff we heard and all the
stuff we said and all the questions we asked and all the answers we heard into
play. So we are going to open up for discussion now as to how we proceed.
Agenda Item: Subcommittee Discussion
Simon had put a few things down. I think it is a good place to start. So
let’s let him take it off, and then we’ll jump in.
DR. COHN: I am just reflecting on what I heard. This is not meant to be the
best statement, but just are some ideas.
I do also want to frame our conversation. As a public advisory committee
whose responsibility is to advise HHS on implementation, our job is to think
about how we can help the public, the whole private sector, move forward
orderly and successfully with an implementation. Our job is not to enforce
compliance or mandate things that are either irresponsible or impossible or
make people do things. Our view is, given the environment that we are in, we
need to try to be as helpful as we can to advise HHS and CMS on how best to do
I think I commented earlier that without legislation you can’t really delay
implementation. So I think whatever we are talking about, it is framing it in
the context of contingency plans and how we would proceed on from that May
I should also comment that our role is probably also not to draft a
complete project plan about how this might be approached, nor of course do we
have knowledge of when the data dissemination notices may come out or not.
At least from what I heard, and I am just throwing out a couple of things,
number one is, in some ways I did not hear any major barriers to providers
getting NPIs, or at least applying for them by the deadline. I would say that
as I look at the regulation, it isn’t that they have to have it; I think they
have to have applied for it by the deadline that we are describing. I’m sure
Karen could probably fine tune that for us.
So in some ways that is the least issue here, though it is the fundamental
first step. So we need to do everything to encourage that first step to occur.
So I think whether we continue with that expectation, I think that is up to the
subcommittee or the full committee, but I think that is something that doesn’t
appear to onerous for anyone.
Now, once you go from there into the next steps, we have some dependencies
on the NPPES database and the uncertainties related to that. We heard about
issues that many providers may not have systems that can accommodate the NPI.
We heard the health plans, many of them are going to be capable of doing
things, but not all uniformly by that May date.
So I think we need to be thinking about some sort of period of time after
that May deadline that would involve testing and contingency implementation,
taken by various differentiations between the multiple meaning of dual. We
probably want to think about as much flexibility as we can with that testing
As I listened to everybody, and I would defer to all of you to think about
it, but it seems like there is a role for the NCVHS in continued monitoring of
any sort of a contingency period. So this is not open ended.
So the question is, we may start out with a contingency period, but we
might also say it needs to be extended, or we might want to advise CMS about
further extensions if necessary, though it might not go quite as long as some
of the longer implementation periods, but also not terribly short, either. I
threw out six months from the May date, which is ten or 11 months from now.
The final piece is, if we are recommending something like this, we would
want to probably take the pulse of the industry sometime probably late summer
or something like that, to see whether further extension of the contingency is
warranted and also what type of contingencies should occur.
This is a straw dog based on what I was hearing. I’m sure you all are going
to want to move it by 60 degrees, but I think we need to make sure we try to
keep it simple.
MR. REYNOLDS: There are a lot of people in the audience that may not be
here tomorrow. We were going to go through our plan for the rest of the year in
hearings. Things we had already noted for discussion is whether or not in each
of our hearings, if we were to have anything happen, we would continue to
receive updates and further make recommendations.
Also, we have another subject we are going to talk about tomorrow,
standards, why can’t we ever get them done on time, was another item that we
were going to consider as we looked at it. So just so you are aware, those are
things we were going to discuss tomorrow, if you are not here.
Simon has put a straw position on the table. Jeffrey, you had a comment?
MR. BLAIR: Yes. Simon, I agree with your first point. I feel like there is
consensus on the first point. I think that there was, out of the three points
in the payor panel, it sounds like we have backed away from the third of the
three points, which is whether or not we begin testing on May 23.
The second point I think we may need to clarify, but I think it would be
unfortunate if we just omitted it entirely. The second point was that by May
23, when a provider has not just applied for their NPI, but received it, and
communicated it to at least one payor, at least one payor, so that the process
of testing can start. I thought that there was consensus during the payor panel
on that second point.
I think it would be helpful for us if we could at least wind up indicating
that those two requirements are retained for May 23. Then there will be some
integrity still left to the May 23 deadline, even if we give additional time
extensions for testing. MR. REYNOLDS: Comments from the rest of the group?
DR. WARREN: It is in reply to Jeff, because I want to be sure I understand.
My understanding is, May 23 is the deadline, period, and we have no control
over that. That is what the regulatory body has said.
What we are having the hearings about is where is the state of readiness to
meet that May 23. We have heard some recommendations that there be some
contingency plan put into place, that people are looking for us to recommend to
CMS, but CMS still gets to make that decision. Nod if I’m right, Karen.
MS. TRUDEL: HHS.
DR. WARREN: HHS, I knew I had the wrong letters. So I am a little confused
about some of the dialogue that we are having. I think everybody is in
agreement that yes, conceivably everybody can go and get their NPI by May 23.
Whether they will, whether they want to, whether they understand or anything,
there is nothing in the testimony we have heard today that prevents that
Now, sharing that number with people; there is still a lot of concern based
around identity theft, and some of the concerns about what sharing that number
means. So I understand that part. There is still nothing to prevent that
happening by the 23rd, other than peoples’ misunderstanding or misconceptions,
or maybe even some real concerns. I think I remember some of the people saying
that the providers have talked with their legal advisors or their business
advisors, and there was this question about there, and they are waiting for
some of the dissemination policy to understand what the security would be on
sharing of those numbers.
Then I think we heard major concern that people don’t think they can get
the testing done by the 23rd.
So I think is my understanding, which I think is a little bit different
than what Jeff is coming up with.
MR. REYNOLDS: Other comments?
MR. BLAIR: I think there is a convergence, if I can. That is the reason I
would up saying, if the providers shared it with at least one payor, if that is
the minimum threshold, it could be their primary health plan that they work
with, in terms of reimbursement, then that is sufficient to comply with my
understanding of what the regulation says we have.
It doesn’t have to be displayed, it doesn’t have to be on the NPPES at that
point. It just has to be with one primary payor so that the process can begin.
So that was the clarification that I was making.
The third piece you and I completely agree with, that is, that the testing
issue is ambiguous in terms of the NPPES. So that is why I tried to separate
that out completely.
MS. TRUDEL: I would like to clarify what the regulation requires. It
requires compliance, which means that a covered entity, whether it is a
provider or a plan or a clearinghouse, has to be able to do its job, submit a
claim, accept a claim, create a remittance, whatever, using the NPPES on HIPAA
transactions. If the NPI isn’t there, the transaction is not compliant,
according to the regulation.
MR. REYNOLDS: I understand.
MS. TRUDEL: That is what brings up the next question, which is what
flexibility does the Department have. Simon mentioned, and I just want to
reiterate it, the Department doesn’t have the ability to extend the date
unilaterally, but we do have the ability to invoke a contingency where we would
be flexible in our enforcement.
DR. CARR: Just following up on the way Jeff has framed this, if we broke it
down into a couple of steps, first one, get it, are there obstacles to getting
it, insurmountable obstacles. It sounds like no. Share it; the obstacle there
is a perception that may be a misperception, so perhaps not possible to
The third one is test it. There, I think we do have some significant
obstacles in terms of software not accommodating it or folks not being able to
afford an upgrade on their software. So I think that is where we have it.
I think the fourth one, test it but then use it, as Karen said, I think
there we have heard about significant unintended consequences, namely, a
beneficiary cannot get their medication, and folks can’t get paid.
So I think as the day wore on, the urgency that we heard this morning
wasn’t as urgent later in the day. I think that is because we moved from the
site of service on the front end to the back end. I think we have the real
urgency and unintended consequences being dealt with on the front end, where we
have people scrambling to check numbers, calling other people to double check
the number or turning people away without their prescriptions.
DR. STEINDEL: Harry, can I ask a clarification?
MR. REYNOLDS: Yes, you can ask a clarification, then I am going to try to
DR. STEINDEL: My question concerns the use of the word sharing. I am
assuming that the reluctance to sharing which we have already heard is a false
supposition, but assuming that they have fears of sharing, I am assuming that
is sharing only outside of the claims, because they are required to put it on
claims. So that is the distinction I would just like to make sure everyone
understands, that that is the meaning of the word sharing.
MR. REYNOLDS: We talked earlier about treatment payment in health care
operations as well.
DR. STEINDEL: Yes, and you should be able to share in that. But it sounds
like they are reluctant to share it. Like, for instance, if a payor sent a
notice to providers and said, we are trying to assemble a crosswalk database of
our NPIs, please provide it. What I understand is that people are reluctant to
do it in that situation.
MR. REYNOLDS: I think in some cases.
DR. STEINDEL: That is why I am asking the clarification.
MR. REYNOLDS: There are some discussions about that, yes. There are certain
circumstances, maybe so.
DR. WARREN: That is what I want to follow up on. As I heard Justine talk,
and even more so with Steve, I’m not even sure with us asking the question can
they share it is even relevant to our discussion.
It sounds like what Karen is saying, if you want to get paid, you put your
number on there. It is only when we get to this other piece, because we don’t
have the data from another source other than a person, that maybe some of the
plans are proactively asking for these numbers, which is not required by the
regulation. It is just a business practice, or trying to get ahead of the game.
So I’m not sure that that is something — maybe that second question is not
relevant for our deliberation. What we are looking at is, can they get the
number, and can we test the processes to insure an accurate submission of the
claims data by May 23.
MR. REYNOLDS: Let me summarize a little bit, based on what everybody has
The first issue is that everyone can move to individual readiness by May
23, but it will not be an integrated end to end solution. I think that is what
we heard. Forget the regulation; I think that is what we heard. In other words,
they can get it, but integrated end to end, that is a concern. So that is just
The second thing we need to do is, the NPPES and the dissemination notice
need to be made available. They are available to CMS. I think somebody put it
as clearly and on a level playing field to the industry, and I think it needs
to be available.
Third, we need to continue outreach. There needs to be continued outreach.
Nobody can pull back. Everybody must continue going forward, and everybody in
the industry and all the people in this audience need to not ever let up,
because none of this stuff happens accidentally.
Four, providers need to get their numbers. Five, they need to share them
with their partners.
DR. WARREN: Let’s be careful saying share.
MR. REYNOLDS: Well, they need to communicate, whatever word we want to use,
and we will adjust those words.
Six, clearinghouse and payors need to be ready to process after May 23.
Then the question I am struggling with, the next piece, let’s say that
whenever that happens, and we heard from WEDI that whenever that happens, the
NPPES example was when they kicked their clock off. When that is available and
it is really available.
Then we have two issues to wrestle with. One, this idea of starting
testing. There are ways to start testing, which is, test however you want to,
that is one. Second is this dual use, where if you are ready to test, you give
both numbers and you test. Then there is the third which I heard from WEDI,
which is one step further, which was, effective after May 23 and after NPPES
and dissemination is available, you must submit your claims with both numbers,
or they shouldn’t be processed.
MR. BLAIR: No, with the NPI and an optional legacy.
MR. REYNOLDS: No, it is only optional if you are new, or you have already
certified, yes. But I want to be careful with the optional.
MR. BLAIR: I think we have to be careful.
MR. REYNOLDS: That is what they said. Then, how long do we expect this
transition to be before we would want to weigh in heavily again, or what would
be the deal.
So that to me is what the thoughts are. I would love comments on whether or
not that — and the pharmacy is a little bit different, we need to fit that in.
DR. WARREN: I heard one other step from WEDI that is not in there. Maybe it
is just that everybody assumes it happens. They put out specifically in their
testimony that once the system has been developed and in place, you need to
train people to use that accurately in order to be able to submit the claim.
They were estimating anywhere from one to 30 days to train people how to
accurately do this, to get the claim ready to submit. That is after their
software is — so it is training people to use the software in their processes.
We did not address that.
MR. REYNOLDS: Train who?
DR. WARREN: The staff in the office.
MS. GREENBERG: The provider staff.
DR. WARREN: The provider staff who does the bill. Those people have to be
trained how to produce that bill.
MS. KUPPE: (Comments off mike.)
DR. WARREN: Right, the office staff.
MR. REYNOLDS: The reason I was pushing you, when you said they, I wanted to
make sure it was clear who they was.
Now, we laid out a structure. Again, we are not writing a letter yet. Does
anybody have any difference of sense as to that these are the steps? I’m not
saying they are nice and I’m not saying they are in order.
DR. FITZMAURICE: Just a thought with some questions. Suppose we were to say
something like, if the NPPES was available to the industry in reasonable
format, and if the claim has only the legacy ID, then you could delay payment
for an additional two weeks. But if it has a valid NPI or if it has both the
NPI and the legacy, pay immediately?
There are a couple of problems. What do you do if the referring physician
doesn’t share his NPI with you? You won’t get paid unless the referring
physician gives you the NPI. Secondly, what if the clearinghouse or the payor
can’t process the NPI? Do they pay double? I don’t know.
MS. TRUDEL: I just wanted to clarify what your first point was, because I
missed it, the one before the date of dissemination being critical.
MR. REYNOLDS: The first one was, what we heard today is that everyone
should be able to get to May 23 — the other thing is transaction to code sets,
and it is here in the same place. It could go in 5010 and could go in ICD-10.
It says there is a due date of May 23. So everybody can award themselves
individually that they are ready. Collectively it doesn’t work.
That is the issue. That is our issue that somebody brought up as we look at
how do we get better at doing standards. There probably needs to be something,
because everybody running through the same goal line means that we all throw
our hands up like we scored a touchdown, and the problem is, that was a relay
race. Nobody ever handed it off.
But I think we have got to start looking at this a little more like that.
Yes, the regulation demands philosophically that everybody have everything
done, but the jurisdiction over making that happen, we have found, and the
ability of the industry to pull that off is what continually is an question.
Without somebody going first and somebody going second and something going
third and something going forth — whether the NPPES is needed.
Now, some people did their implementation assuming that NPPES was
available. I think Patrice touched on this, that she had to change but others
didn’t necessarily change. So there has been some beliefs out there, and if
those beliefs get torn asunder, then all things happen.
So we have a single date, and everybody is marching to that date, so you
can’t really say to somebody, you didn’t do what you did, and they say, I’m
ready. The problem is, they are not all ready together. So that is what this
first one is trying to say.
MS. TRUDEL: I think we did hear that everybody should be able to get ready
by May 23.
MR. REYNOLDS: No, we didn’t hear that.
MS. TRUDEL: I mean, get to ready.
MR. REYNOLDS: Get to themselves being ready. I’m good with that.
MS. TRUDEL: Should we able to. But it sounds as though a large number of
MR. REYNOLDS: That is why I went back to the dual use for testing. I went
back to those three different ways, so when you get to May 23, what do you
allow. WEDI’s recommendation is, you don’t allow anything other than the fact
that you have got to do both. So that is the one I left unclear as to exactly
what this committee might or might not want to say.
MS. TRUDEL: But there still may be a somewhat significant number of
providers that for whatever reason do not have an NPI by May 23.
MR. REYNOLDS: We heard some testimony to that, but we heard other
recommendations that that should be the hard stop. I’m ont debating the point.
MR. BLAIR: I think in order for us to carve this out in a way, I think we
have to completely separate whether the NPPES is available or not on or before
May 23, and just figure exclusively what we feel must be ready by May 23, and
then separately wind up taking a look at if it is ready before or after, how
does that change things.
But I think we have to completely separate these, because if we don’t, I
don’t think we are ever going to be able to come to an answer on this issue.
MR. REYNOLDS: Tell me more. I’m not sure why you separate.
MR. BLAIR: I think we cannot assume that the NPPES will be ready by that
date. So we are in a situation where I think there is a basic minimum. If you
assume that it won’t be ready, then what can you still expect by May 23, start
with that as your first piece, and then if it does happen to be ready on or
before that, then there is some additional expectations.
MR. REYNOLDS: I guess the only reason I would struggle to do that, Jeff, is
that at some point there needs to be some kind of a single source of the truth.
That NPPES would at least be a base single source of the truth. Otherwise,
everybody builds their own source of the truth and tries to share.
I have already used the example of claims going back and forth from payors
to CMS and CMS to payors, and without a single source of the truth, you are
finding yourself in a situation where everybody is deciding what NPI does or
doesn’t mean and what it does or doesn’t look like. Just because a provider
told me a number and then told Medicare a different number, then the world is
now going beside each other.
So that would be my hesitation, Jeff, in letting that not be a key part.
MR. BLAIR: If you go down that path, Harry, and I am willing to go down
either path, we need to go down the path of saying that it is really important
that something meaningful be retained for that May 23 date, in terms of
deliverable date, or if we go down the path you suggested, what becomes
meaningful is when the NPPES becomes available, and that starts the clock for
when everything else works.
DR. WARREN: Is there anything in the regulation about compliance that says
that the NPPES will be available prior to May 23?
MS. TRUDEL: No.
MR. REYNOLDS: However, is it not identified as the enumerator.
DR. WARREN: Is it part and parcel of being compliant.
MR. REYNOLDS: That is correct. However, it is the official enumerator, and
having it not available to people says that the official source of the truth is
not available to people.
DR. WARREN: But by being the official enumerator, nothing was ever said.
All that was said was that we would give you your number and it would enumerate
you. There has never been something said, oh, by the way, we will provide you
with this database so that you can be compliant.
MR. REYNOLDS: Maybe not in the regulation, but I think it has been —
MS. GREENBERG: It does say there will be such a database. The assumption
had to be that it wouldn’t be hidden.
MR. REYNOLDS: Remember, we are recommending how to get this done, not just
the letter of the law.
MS. TRUDEL: The final rule did say that data would be disseminated. It
didn’t say how much of it, didn’t say how, and then said that we would do a
data dissemination notice to provide that information. So that is pretty much
what was in the preamble of the final rule.
MR. REYNOLDS: And this committee is on record from our last letter that
that needed to happen, from testimony that we heard from the public that that
needed to happen quickly.
DR. WARREN: So if you follow the logic statement, if the data isn’t
disseminated and available by the 23rd, no one can be in compliance,
MR. REYNOLDS: I couldn’t draw that line. It is important.
DR. WARREN: I am trying to understand what all this means.
MR. REYNOLDS: You might not be in compliance with everybody, but you can be
in compliance with some.
DR. WARREN: Got it.
MR. REYNOLDS: And over time, could be incredibly detrimental, because you
don’t have the single source of the truth.
DR. STEINDEL: I would like to pick up on these comments and on Jeff’s
concerns. I think that I am hearing around the table a relatively clear
consensus that we feel that full enumeration can be accomplished by May 23. I
think in terms of what Jeff is asking, that is a hard stop.
As Karen pointed out, there may be people who don’t enumerate, but I think
that is always going to exist. But I think we need to observe that we need to
keep on going and try to enumerate one hundred percent of the eligible
population by May 23. That should be everyone’s goal, and we should make that
So there is Jeff’s point.
Now, in addressing somewhat Harry’s comment that he just made, I think we
need to note that after May 23, the NPI — and it can be used even before, but
after May 23, the adjudication part of the system, the claims, the payors, et
cetera, all should be in place to process an NPI.
Now, whether they can process a claim successfully on an NPI or not depends
on the point that Harry just made. That is, there are probably going to be a
bunch of local transactions where all sets of NPI are in place, and you can use
that to handle the claim, but you cannot guarantee that the whole claim system
can handle just the NPI until the NPPES is available. That is what we have
So if we want to say you can totally drop using legacy numbers, we have to
put that date sometime after NPPES becomes available. At least, that is the way
I understand it.
Harry, am I paraphrasing what you said relatively correctly?
MR. REYNOLDS: I’m not necessarily agreeing with that. But, Simon, you had
your hand up.
DR. COHN: Maybe this is going back to earlier discussions. I was A,
assuming that people are ready for testing at some point. I am wondering if we
are somehow trying to connect the NPPES piece into a time line, it sounds like.
I am wondering if the point is to make a strong recommendation if this thing
needs to be out as quickly as possible, and then we also make an assumption
that by May, this thing would be available to everyone in terms of there being
a letter like that.
As I said, I have no idea how long this is going to take. This whole issue
of trying to take things from a time line of when NPPES is available is to me
fraught with some difficulty. You are trying to figure out what the time line
is you are talking about.
Testing to my view is different than successful transmission of having
everything end to end complete. That can be started and already is, even in the
absence of NPPES.
I’ll stop talking.
DR. FITZMAURICE: I want to support what Simon said. I wonder if this has
even bigger problems than not paying claims. It would seem to me that without
NPPES, which is the source of the truthful relationship between the NPI and
identifying information of the provider, opportunities where fraud and abuse
are increased. Somebody could more easily masquerade, because you can’t get at
the truthful relationship between the NPI and the identifying information. That
would seem to be an argument that would weigh pretty heavily.
MR. REYNOLDS: We are near adjournment. A couple of things. One, I think we
have had an excellent day of testimony. We have heard so many differing things.
I think we have had a good internal debate amongst ourselves on what we think.
I don’t think we are going to write a letter tonight. We have got some more
time tomorrow to discuss some things.
I think at this point, continuing to iterate the details or talk about the
flow, I think we are all getting more and more apart on what we remember and
what we think and what we heard. So I would recommend that we spend a little
time. We have time to discuss this tomorrow, and we are going to need to make a
decision before this whole hearing is over as to whether or not we are going to
put a letter together, what it means, what it doesn’t mean. So we will have
time to talk about that further tomorrow.
I’m not sure deliberating any more today, of coming up with a chronology or
coming up with the wording, or coming up with whether we agree or disagree with
each statement we are each making will turn it into a never-ending discussion.
I’ve got one other quick thing to talk about, so I would like to stop this
discussion at this point, knowing that there is no question that we have been
handed a large task. If you notice, the audience testified and ran.
MR. BLAIR: I think you have consensus on adjourning.
MR. REYNOLDS: No, I’m not adjourning yet. The other thing I would ask you
to do is, each of you were given this handout. You originally got the chart
that we sent out to everybody that showed the things we need to consider.
We have subsequent to that in discussions among Simon and Jeff and myself
tried to break our issues into our clear subjects. You will see a little
different wording on overlap; it is really synergy with others. Then the last
is things we would want to look forward at, because we have got to figure out
what our hearings are the rest of the time.
The second part of that document spells out possibly the other two or three
hearings this year. It lists under there definite things. For example, if you
look at hearing number two, one definite is an NPI update. So whatever we do,
whatever letter we create, whatever happens, I would say we will have NPI
updates all this year, however many hearings we have.
E-prescribing, I understand that is going to Congress in April, depending
upon when the second hearing is. It may be the third hearing and it may be the
fourth hearing, understanding what is going on with e-prescribing, which is one
of our charges.
Then you have got items under consideration. In the consideration column,
if there are things that we have synergy with others, for example, if we had to
get involved more in secondary uses or anything, then that may move over into
definite for that hearing. And we have some other things listed.
So tomorrow, we need to set an agenda for at least two other hearings this
year if we plan to have them, and decide on whether we would need three. But
the main point is, this is clearly laid out for you based on us trying to set
some priorities. So tomorrow we need to settle on this, get some dates, so we
can start polling people for dates, and have something to do clearly that is
going to deliver some work the rest of the year.
So I ask you to look at these and make sure that at the end of 2007, if we
did what this says, you would feel that we have moved many balls forward in
many right directions. Let’s don’t just have hearings to have hearings, let’s
don’t talk about subjects to talk about subjects.
PARTICIPANT: (Comments off mike.)
MR. REYNOLDS: Those are new subjects that we haven’t spent time on.
So with that, is there any other business for today’s hearing? I’d like to
thank all the testifiers, thank the committee for staying focused, we really
appreciate it. Thank you.
(Whereupon, the meeting was adjourned at 5:40 p.m.)