The National Provider Identifier (NPI) is a standard unique 10-digit numeric identifier assigned to healthcare providers and organizations defined as covered entities under the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The purpose of the NPI is to replace all other provider identifiers previously used by healthcare providers (for example, UPIN, Medicare/Medicaid numbers, etc.). Health plans are required to use only the NPI to identify covered healthcare providers in electronic transactions by May 23, 2008 (The original deadline was May 23, 2007; the industry adopted a contingency plan to allow a year to gain full compliance).
Who would have thought that a mandate to implement simple, 10-digit National Provider Identifiers would be so complicated? When you consider the fact that existing legacy numbers are tied directly to every aspect of a payer’s business — including claim payment, provider contracting, credentialing, reporting and communication — all of a sudden, the numbers used to identify providers take on a whole new meaning.
At Blue Cross Blue Shield of Massachusetts, we accepted the NPI compliance challenge and addressed it with a 3-prong strategy that involved:
1. Re-designing business strategy, rules and workflow to successfully map legacy identifiers to new NPIs, without losing or mismatching critical provider data.
2. Assembling the right team.
3. Proactively communicating with providers, both independently and collaboratively with other payers in our market, and the entire BCBS of Massachusetts organization.
We began the NPI initiative in early 2005 by assembling a cross-functional team of both business and technology professionals from our organization and our system integrator, EDS. The team studied the NPI mandate, analyzed our systems, and assessed the impact to the entire enterprise. More than 150 systems and applications were assessed, and about half were found to require some form of remediation. Our biggest challenge was to develop a strategy for the crosswalk solution.
The key goal was to successfully map legacy identifiers to the new NPI numbers without losing or mismatching critical provider data. One of the early challenges to the NPI project was that we were in the process of replacing our core systems as an effort to be more efficient. We were also investing heavily in more provider facing applications through Web portals. With these and other corporate initiatives competing for resources, we didn’t have the time or the money to design and build an NPI solution in house.
We tapped our long-standing partner, EDS, which has an understanding of our IT environment and goals as well as our business objectives, to help us find the best ready-made solution out there. EDS' integration and development capabilities and their ability to manage vendors and third parties in support of us made them a good partner.
We picked the Portico Systems NPI Solution for five reasons:
- It offers out-of-the-box functionality
- It’s scalable as our business needs grow and change
- It’s compatible with our existing architecture
- Because the crosswalk resides outside of our legacy system, it doesn’t impact overall business performance
- The company has a good track record with other BCBS plans
Paving the way for NPI
Our cross-functional team included dedicated resources from Portico Systems. The first order of business was to develop our approach for mapping our legacy identifiers from electronic transactions that utilize provider NPI data. We had the monumental task of linking more than 150,000 legacy provider numbers that had to be cross-walked to the correct NPIs.
Portico helped us develop business rules to describe how we use the legacy numbers so that we could map them correctly for NPI. Since the NPI provider identifier used for external interfaces is now different than the legacy provider identifier we use for internal processing, we examined our workflows to determine if any changes would be needed. The team identified more than 200 business process flow changes and several new workflows that were needed to support the use of NPI in our business operations.
Since our decision to select Portico Systems for our NPI crosswalk was made in mid-2006, our biggest challenge was to implement and populate the crosswalk at breakneck speed. Our target was to implement the crosswalk within our environment by early 2007, to maximize our window to test with providers in advance of the May 23, 2007 compliance deadline. With such aggressive goals, we needed to organize our work teams effectively for success, finalize our architectural and conversion decisions quickly, and begin to define and test our crosswalk business rules as soon as possible. An additional challenge was that we didn’t understand how difficult it would be to attain NPIs or how providers would actually choose to enumerate.