[This Transcript is Unedited]
National Center for Health Statistics
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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 Hospitals.
MS. MAGOFFIN: Carole Magoffin, representing the National Minority Quality Forum.
DR. FITZMAURICE: Michael Fitzmaurice, Agency for Health Care Research and Quality, liaison to the full committee, staff to the Subcommittee on Standards and Security.
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 Programs.
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 something.
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 minorities.
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 numbers.
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 percent.
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 measures.
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 citizens.
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 populations.
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 NPI implementation.
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 reprot.
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 NPPES.
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 those payors.
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 improved practice
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 Inglewood, Colorado.
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?
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 referring provider.
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 correct provider.
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 implementation date.
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 testing.
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 delayed.
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 communities.
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 in December.
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 note.
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 be.
Number two.
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 percent.
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 have.
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 employed.
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 recognition.
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 having it.
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 physicians.
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 water.
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 smooth transition.
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 correct.
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 issue.
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 physician?
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 claim.
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 difficult.
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 process.
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 your help.
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.
(Brief recess.)
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 listening.
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 clearinghouse.
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 industry.
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 NPI.
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 testing identifies.
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 HDX network?
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 inconsistency.
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 there.
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 concrete steps.
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 crosswalk solution.
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 force.
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 system.
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 it.
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 match.
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 transactions.
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 time.
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 widespread issue.
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' offices.
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 mentioned before.
We discussed differing payor requirements, differing payor implementation schedules, the crosswalk implementation, enrollment and taxonomy codes confusion.
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 more.
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 organizations.
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 good.
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 earlier.
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 data.
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 those practices.
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 that correct?
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 it.
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 this possibility.
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 nature.
MR. REYNOLDS: For everybody's understanding, that is transactions to code sets, right?
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 help us.
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 clearinghouse piece.
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 again.
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 work.
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 get there.
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 normalization.
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 lunch.
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 the vocabulary.
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.)
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 Vilaret first.
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 this time.
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 system.
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 23 deadline.
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 Delaware Medicaid.
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.
Thank you.
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 numbers.
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 the files.
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 perspective.
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 more.
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 last minute.
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 that.
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 confusion.
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 NPI?
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 processes succeed.
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 order pharmacies.
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 23, 2007.
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 application.
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 collecting NPI.
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 made available.
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 again.
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.
Thank you.
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 concern.
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 May 23
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 time.
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 database.
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 whatever.
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 reference.
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 like?
DR. VILARET: They haven't even asked. There has been not any kind of discussion.
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 pharmacies.
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.
(Brief recess.)
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 million Americans.
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 requirement.
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 implementation progress.
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 possible.
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 appropriately processed.
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 testify.
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 compliance.
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 learned.
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 incurred.
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 on time.
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, welcome.
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 correct one.
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 legacy number.
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 COB transaction.
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 incoming claim.
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 enumerated.
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 three states.
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 million?
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 number.
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 reason.
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 work?
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 format.
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 think?
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 earlier discussion.
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, right?
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 date.
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 obtaining --
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 roadblocks.
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, would.
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 out there.
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 reporting it.
MR. BLAIR: So the data dissemination policy, you are referring to the NPPES?
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 HHS' possession.
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 that effect.
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 people are.
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 source.
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 dissemination notice?
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 know.
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 May 23.
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 be safeguarded.
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 things.
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 implementation.
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 WEDI.
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 begin testing.
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 enrollment form.
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 organization IDs.
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 activities.
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, ordering, prescribing.
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 effective manner.
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 time.
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 barriers.
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 of testing.
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 manual process.
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 be.
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 community.
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 not.
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 every claim.
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 here.
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 for.
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 pharmacy recommendation?
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 need.
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 pharmacy.
MS. VILARET: First of all, pharmacy claims only allow us to submit one prescriber number.
MS. KUHN: There is only one data field.
MR. REYNOLDS: So compared to the 837, you only have one number in your standard transaction.
MS. KUHN: Right.
MS. VILARET: Exactly. So we submit either a legacy number or NPI, that's it.
MS. KUHN: And it cannot accommodate health care provider taxonomy codes, either.
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 recouped.
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 piece.
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 testing process.
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 by 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 water skiing.
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 that.
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 background.
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 anymore.
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 others.
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 pieces.
DR. CARR: I wasn't clear on what is the assumption that NPPES is available, what day.
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, unnecessarily.
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 number.
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 this.
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 date.
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 period.
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 happening.
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 overcome.
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 sum up.
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 said.
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 a statement.
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 them won't.
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, regardless.
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 very clear.
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 heard.
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.)