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Crosswalking the NPI Chasm, Part II

April 11, 2007
by Walter Suarez, M.D., MPH, and Joel Portice
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Any NPI strategy must clearly spell out both solutions and results.

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

The solution: The crosswalk to compliance

Checklist #3: Key Steps to the Crosswalk Approach

¨ Cleanse provider data

¨ Gather NPIs

¨ Use a data-matching tool to map legacy IDs to NPIs

¨ Create and utilize an accurate crosswalk file

The crosswalk approach

Many health plans are taking a similar approach to NPI compliance, continuing to use legacy IDs internally, and matching them to the NPIs with inbound transactions and converting them back to NPIs for outbound transactions — a strategy commonly known as a crosswalk approach. This strategy is a popular technique as it allows health plans to minimize the impact to legacy systems.

Crosswalk from legacy to NPI

Although many health plans may feel comfortable with the crosswalk approach, they must anticipate several data-matching issues. First, most healthcare organizations have dealt with inferior provider data for decades, but the problem of incomplete and inaccurate information will only serve to intensify the complications in linking legacy IDs to NPIs. Due to the benefits of clean provider data, many health plans are using NPI compliance as the impetus to finally deal with their recurring provider data problems. By fixing data problems first, health plans will dramatically increase their matching rate and accuracy. Cleaning existing data, in which (frequently) more than 50 percent of provider information is either missing or incorrect, is a critical step to streamlining the NPI crosswalk strategy.

Second, there are the issues of many-to-one, one-to-many and many-to-many relationships between legacy IDs and NPIs described previously (in the first part of this article). To overcome these multi-relational challenges, many health plans are employing a process by which the NPI is matched to as many appropriate legacy IDs as possible. To do this, plans utilize data-matching tools that review all data sources and fields to find the most likely legacy matches/candidates.

Some health plans may opt for a rules-based matching process, but for the most part, this effort is inadequate for plans with multiple databases, information systems and complex provider identifiers. Business rules engines are suited to plans that currently employ a single-ID approach.

For the most part, data-matching tools that utilize advanced analytics are more appropriate. In addition, a referential database of provider information can also assist in the legacy-NPI mapping process. Through these techniques, health plans will be able to identify and match provider records across various data sets, discovering shared elements that might otherwise go undetected. The result is accurately linked identifiers that contain the best available provider information.

In using a crosswalk strategy, health plans must allow sufficient time for mapping, system modifications, testing, provider outreach and potential re-enrollment activities when necessary to ensure comprehensive compliance and complete transition to the NPI and HIPAA compliance.

NPI collection

Although many health plans are well on their way to having established a crosswalk file, collecting NPIs to match to legacy IDs is still a significant obstacle. The Centers for Medicare and Medicaid Services (CMS) has said that it would disseminate NPI files to health plans, and payers would prefer this method — simply downloading a comprehensive NPI file to match against their provider databases.

However, CMS has delayed any guidance on how or when this might occur. As such, health plans must move forward and begin collecting NPIs from providers now, in order to comply with the deadline date. Some plans are asking their provider relations department to get involved in collecting NPI information, while others have modified electronic claims processing to allow systems to automatically collect NPIs as transactions are submitted. Other plans are using their Web sites to collect NPIs from providers.

In addition, other plans are working with their largest provider groups to collect their NPIs via bulk electronic files (for example, pre-formatted Excel spreadsheets).

A transition plan

As previously discussed, health plans should utilize a transition period in which they accept NPIs along with legacy IDs. The transition would use a multi-phased process. In the first phase, NPIs would be optional, and legacy IDs required. The next phase would require either the NPI and/or the legacy ID, and the final phase would require NPIs and reject transactions that do not include this information.

Testing and verifying

As providers start to receive NPIs, health plans must begin to test information systems and their ability to not only accept NPIs, but also run without disruption or system glitches. Health plans should expand this testing to include as many providers as possible. Once a provider's NPI transaction is approved, that provider can start using the NPI on a regular basis.

Organizations should also plan to test NPI exchange with trading partners. In regards to verifying NPIs, at this point CMS has not outlined a method to verify NPIs against a master file, but health plans should plan to incorporate a verification process into their program once it's available.

The result: The NPI chasm crosswalked

With NPI compliance less than six months away, many healthcare executives may start to lose sleep over how NPI implementation is progressing toward the deadline. Although incorporating a simple number change may sound easy, this issue can cause significant consternation, particularly when a comprehensive gap analysis is not performed, and health plans are unaware of potential stumbling blocks along the crosswalk to NPI success.

Unfortunately, for many providers, NPI enumeration is not a high priority, and many that are part of larger provider organizations are relying on them to take care of their NPI application needs. All providers are being reminded at every turn to obtain their NPIs early, share them with those who need them and begin using them in transactions.

Health plans should not underestimate the magnitude of changes required to comply, the impact the NPI implementation will have on their operations, or short change the time and effort needed to transition from legacy identifiers to new NPIs. This case study hopefully provides health plans with a jumpstart to crosswalk the chasm to compliance.

Walter Suarez, M.D., MPH, is president and CEO of the Institute for HIPAA/HIT Education and Research and co-chair of the WEDI NPI Implementation Workgroup and the NPI Outreach Initiative.

Joel Portice is COO and co-founder of Enclarity Inc.

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