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Crosswalking the NPI Chasm

March 30, 2007
by Walter Suarez, M.D., and Joel Portice
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There are some very general steps that any health plan can follow to NPI compliance.

Following is part one of a two-part piece on how payers can revamp their systems to handle National Provider Identifiers. Part one provides an overview of the issues, while the second part, to run in March, examines the "crosswalk" approach.

The fast-approaching deadline for National Provider Identifier (NPI) compliance is cause for concern for many health plans still struggling to sort through myriad changes required to accommodate these new ID numbers. Some plans are well on their way to compliance, while others are just grasping the impact the NPI will have on their business processes, information systems and trading partner relationships.

Provider IDs are one of the most ubiquitous pieces of information in healthcare, critical to capturing key elements in a patient-provider encounter, and used in subsequent transactions and business processes, including claims, authorizations, payments, utilization management and credentialing.

The NPI transforms the historical process in which health plans assigned their own unique proprietary IDs to individual providers and provider organizations and, in many cases, more than one ID to the same provider to distinguish different business relationships, provider locations, contract agreements and payment schedules. Come May 23, 2007, however, plans must cross the chasm to a single identifier standard.

Although compliance creates a host of unique organizational and technical challenges, industry analysts have reported that many NPI implementation managers are using a similar basic strategy — mapping legacy IDs to new NPIs. In considering this "crosswalk" approach, there are general steps any plan, regardless of size or network architecture, can follow on a path to compliance.

Steps to a comprehensive gap analysis

Task force: Compliance with the NPI HIPAA mandate will require more than a high-level assessment to fully understand the impact the NPI will have within the organization. As with any project, the first step is to create a task force with representation from various departments and which will provide the necessary process and technical expertise to ensure a smooth transition.

This task force needs first to perform a comprehensive assessment to identify and understand current provider enumeration practices, business processes, internal systems and trading partner relations that will be affected by NPI implementation. The accompanying gap analysis will enable organizations to formulate a plan that addresses the process changes and system modification required to accommodate the new NPI standard.

Step 1: Review enumeration processes

How a health plan currently enumerates and identifies its participating and non-participating providers will largely determine its unique compliance approach. A critical step in the assessment is a detailed account of an insurer's current process for assigning identifiers to individual and organization providers. For instance, many health plans currently assign several numbers to a single provider with separate IDs differentiating care locations or reimbursement arrangements.

This system will result any one of the following situations:

  • a one-to-one relationship between legacy and NPI numbers (mostly in the case of individual providers that have been assigned a single proprietary ID by health plans);

  • a many-to-one relationship, when more than one proprietary ID is assigned to the same provider (which could be the case for both individual and organization providers);

  • a one-to-many relationship, if a provider assigned with a single proprietary ID chooses to obtain more than one NPI for itself and some of its subparts (only applicable to organization providers, since individual providers can obtain one and only one NPI);

  • and in the case of provider organizations consisting of multiple providers, locations, and specialties, a possible many-to-many relationship.

Organizations must then review the purpose for which they assign provider IDs. If "intelligence" is embedded in their proprietary ID format, health plans may need to utilize additional information and data fields to represent these elements in another capacity.

Two additional factors that add complexity to the enumeration process are the designation of "subparts" and the use of provider taxonomy codes.

Provider organizations, such as hospitals or large physician groups, may apply for and be assigned an organizational NPI, but can also designate one or more subparts with unique NPIs, such as a separate clinic, or a hospital system with different departments, such as inpatient, outpatient and long-term care facilities.


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