Do You Have Your NPI Yet?

The federal government has given the health care industry up to a year-long reprieve in adopting a new standard identification system for use on electronic claims.  But physicians should still proceed to get their new National Provider Identifiers (NPI's) prior to the original deadline of May 23, 2007 as health plans are permitted, but not required, to continue to receive claims with legacy numbers.  For twelve months after the May 23rd deadline, CMS will allow payers to process claims using either NPI's or the older ID numbers without penalty, as long as the insurers have adopted appropriate contingency plans for moving to an NPI-only  system.  Out of the approximately 2.3 million physicians, hospitals, and other entities that need to obtain numbers, about 2 million had applied for NPI's as of early April.  It is important to share your NPI with business partners and other physicians who may need to record the NPI of a referring physician on claim forms.

Over 2 million providers have their NPIs – do you have your NPI yet?  Covered entities (including health plans, covered health care providers and clearinghouses) across the country are making decisions regarding their need for contingency plans for NPI implementation. It is more important than ever to obtain an NPI as soon as possible and begin testing it on claims, as directed by your health plan. 

Medicare providers should pay special attention to the Medicare information section below for important news on the Medicare FFS Contingency Plan. 

New Compliance Contingency Guidance FAQs
CMS has posted new FAQs related to the previously posted NPI Compliance Contingency Guidance.  Questions include:

• What are the exact dates for the National Provider Identifier (NPI) contingency plan?
• If a complaint is filed against me for not being in compliance with the National Provider Identifier (NPI) after May 23, 2007, what will happen?
• What happens if a complaint for not being in compliance with the National Provider Identifier (NPI) is filed against me after May 23, 2008?
• Is it acceptable for a health plan to announce their National Provider Identifier (NPI) contingency now?
• Is the National Provider Identifier (NPI) contingency plan voluntary?
• Am I allowed to give my National Provider Identifier (NPI) to other providers as well as to the health plans with whom I exchange transactions?

 To view these FAQs, you should:

1. Go to the CMS dedicated NPI web page at www.cms.hhs.gov/NationalProvIdentStand
2. Scroll down to the section that says “Related Links Inside CMS”
3. Click on NPI Frequently Asked Questions. To find the latest FAQs, click on the arrows next to “Date Updated”. Look for the word “NEW” in red font to appear beside the most recent FAQs.

Obtain Information on Contingency Plans
CMS strongly urges providers to pay attention to information from the health plans they bill so that they are aware if, and when, a specific health plan announces its own contingency plan.

Reminder – Sharing NPIs
Once providers have received their NPIs, they should share their NPIs with other providers with whom they do business, and with health plans that request their NPIs.  In fact, as outlined in current regulation, providers who are covered entities under HIPAA must share their NPIs with any entities that need them for billing purposes -- including those who need them for designation of ordering or referring physician.   Providers should also consider letting health plans, or institutions for whom they work, share their NPIs for them.

Reminder – Enumerating a Group Practice
A group practice that conducts any of the HIPAA standard transactions is a covered healthcare provider (a covered entity under HIPAA) and, as such, must obtain an NPI. The physicians employed by the group practice, on the other hand, are furnishing services at the group office(s) but they are not conducting any of the HIPAA standard transactions (such as submitting claims, checking eligibility and claim status). As such, the physicians would not be covered health care providers and are not required by the NPI Final Rule to obtain NPIs.  However, as the employer, the group could require these physicians to obtain NPIs and use the NPIs to identify them as the rendering providers in the claims that the group submits.  If these physicians prescribe medication, the pharmacies may require their NPIs in the claims that the pharmacies submit to health plans.  Additionally, health plans can require enrolled physicians to obtain NPIs in order to participate in that plan.  Medicare is an example of a health plan with this requirement.

Reminder – Applying for an NPI Does Not Enroll a Health Care Provider in a Health Plan
Applying for an NPI and enrolling in a health plan are two completely separate activities.  Having an NPI does not guarantee payment by any health plan.

When to Contact the NPI Enumerator for Assistance
Providers should remember that the NPI Enumerator can only answer/address the following types of questions/issues:

• Status of an application
• Forgotten/lost NPI
• Lost NPI notification letter (i.e., for those providers enumerated via paper or web-based applications)
• Trouble accessing NPPES
• Forgotten password/User ID
• Need to request a paper application
• Need clarification on information that is to be supplied in the NPI application

Providers needing this type of assistance may contact the enumerator at 1-800-465-3203, TTY 1-800-692-2326, or email the request to the NPI Enumerator at CustomerService@NPIenumerator.com .

Please Note:  The NPI Enumerator’s operation is closed on federal holidays.  The federal holidays observed are:  New Year's Day, Independence Day, Veteran’s Day, Christmas Day, Martin Luther King's Birthday, Washington's Birthday, Memorial Day, Labor Day, Columbus Day, and Thanksgiving.

Important Information for Medicare Providers
Medicare Fee-For-Service (FFS) Contingency Plan Announced!

FFS Medicare has announced its contingency plan.  View the associated Change Request at http://www.cms.hhs.gov/transmittals/downloads/R1227CP.pdf, as well as the related MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS website.  Please note that these materials were recently revised; please be sure to visit the links above for the latest information.  This information will also be available shortly on CMS’ dedicated NPI web page. 

A national NPI Roundtable on the Medicare FFS Contingency Plan is scheduled for May 10, 2007 from 2-3:30PM EDT.  Registration details to follow.   

Reporting a Group Practice NPI on Claims
Medicare has identified instances where the Multi-Carrier System (MCS) is correcting billing or pay-to provider data on Part B claims submitted by group practices.  As of May 18, 2007, the MCS Part B claims processing systems will no longer correct claims submitted by group practices that are reporting the individual rendering Provider Identification Number (PIN) or individual rendering NPI in either the billing or pay-to provider identifier fields.  Groups should enter either their group NPI or group NPI and legacy PIN number pair in either of these fields. 

Reminder – Medicare Extending Date for Accepting Form CMS-1500 (12-90)
While Medicare began to accept the revised Form CMS-1500 (08-05) on January 1, 2007 and was positioned to completely cutover to the new form on April 1, 2007, it has recently come to our attention that there are incorrectly formatted versions of the revised form being sold by the Government Printing Office (GPO). After reviewing the situation, the GPO has determined that the source files they received from the NUCC’s authorized forms designer were improperly formatted. The error resulted in the sale of both printed forms and negatives which do not comply with the form specifications.   However, not all of the new forms are in error.  

Given the circumstances, CMS is extending the acceptance period of the Form CMS-1500 (12-90) version beyond the original April 1, 2007 deadline while this situation is resolved.  Medicare contractors will be directed to continue to accept the Form CMS-1500 (12-90) until notified by CMS to cease. At present,  CMS is targeting June 1, 2007 as that date. During the interim, contractors will be directed to return, not manually key, any Form CMS-1500 (08-05) forms received which are not printed to specification. By returning the incorrectly formatted claim forms back to providers, we are able to make them aware of the situation so they can begin communications with their form suppliers.

For more details, and to learn how to identify the proper version of the new form, visit a recent MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5568.pdf on the CMS website. 

Still Confused?
Not sure what an NPI is and how you can get it, share it and use it?  As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website.  Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203.

Getting an NPI is free - not having one can be costly.

Mainecare MECMS Update

A combined meeting of the Governor's MECMS Provider Advisory Committee and the Technical Advisory Committee was held on Friday morning, April 27.  The discussion focused on the return of interim payments, the transition to a fiscal agent and an upcoming presentation by providers to the Legislature's Appropriations Committee.

Weekly metrics for the week of 4/22/07 showed that 96.09% of :fresh claims were processed, either paid or denied.  Suspended claims inventory was a 66,464. 

Relative to Interim Payment Recovery, the balance of interim payments made to providers stood at $522 million of which $339 has been recovered and an additional $69.5 million is in a recovery plan.  MaineCare has placed a hold on claims with service dates prior to Jan. 1, 2006 where there is an interim balance due, the assumption being that the claims have been successfully paid by now and that the interim payments therefore represent a double recovery.  This hold will be expanded to claims with service dates prior to Oct. 1, 2006 on May 7.  If you are impacted by the hold and your claims with dates of service prior to these dates have not been paid, you should consult with your provider relations specialist.

Relative to the weekly capping of claims, the capped claims for the previous week (Cycle #41) totaled $14.4 million.

Relative to the transition to a fiscal agent, meeting attendees were given a copy of the Panning Advance Planning Document dated April 9 which was approved by CMS on April 18.  A project team is being formed now.  The federal approval of the document means that the feds will pay for the planning and procurement processes at an enhanced federal rate (90%). 

The projected planning and procurement schedule establishes a contract start date as June 2008. Once a contract is signed, it will then take many months for the transition to the new fiscal agent to be completed.  The RFP itself is not scheduled to be issued until December, 2007.  The estimated total cost of the project, based upon recent MMIS activities in other states, is $80 to $100 million dollars.  Most of this cost will be paid by the federal government. [return to top]

Medicare Fee-For-Service (FFS) NPI Implementation Contingency Plan Announced

FFS Medicare has announced its contingency plan.  View the associated Change Request at http://www.cms.hhs.gov/transmittals/downloads/R1225CP.pdf, as well as the related MLN Matters article at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5595.pdf on the CMS website.  This information will also be available shortly on the dedicated NPI page.  A national NPI Roundtable on this topic is scheduled for May 10, 2007 from 2-3:30PM EDT.  Registration details to follow.    

As always, more information and education on the NPI can be found at the CMS NPI page www.cms.hhs.gov/NationalProvIdentStand on the CMS website.  Providers can apply for an NPI online at https://nppes.cms.hhs.gov or can call the NPI enumerator to request a paper application at 1-800-465-3203. [return to top]

MMA Proposes to Tighten up AMA Physician Data Restriction Program (PDRP)

The MMA delegation to the AMA, led by delegation chair David Simmons, M.D, is submitting a proposed Resolution to the AMA in June which, if passed, would place further restrictions on the AMA's Physician Data Restriction Program (PDRP).  The Program, established in 2006, allows physicians to protect their individual prescribing data.  However, the PDRP permits the data to be shared with pharmaceutical manufacturers, who, under contracts with the AMA, agree not to share the physician's prescribing profile with detail personnel who may visit with the physician.

It is the opinion of MMA that physicians who choose to opt-out of sharing their data must be ensured that the data is not shared with the company, or at least be offered the choice.

The Resolution, which was unanimously supported by the New England delegation to the AMA on Saturday, reads as follows:

     Whereas, our AMA has established the Physician Data Restriction Program (PDRP) allowing physicians to make an informed choice regarding the sharing of their individual prescribing data; and

Whereas, the PDRP prohibits the release of such data to pharmaceutical representatives but permits the data to be shared with the pharmaceutical manufacturers who in turn, have agreed not to share it with individual detailing personnel, and

       Whereas, physicians who opt-out of sharing their prescribing data through the PDRP deserve assurance that the data will not be utilized for sales and marketing by a manufacturing company or its individual representatives, and

       Whereas, our AMA's current contracts with the manufacturers do not ensure such protection,

       Therefore, be it Resolved that our American Medical Association develop and implement changes to the Physician Data Restriction Program (PDRP) such that a physician could choose to prohibit the use of their own data from being shared for any purpose but would create a second option that would allow the sharing of data for public health, research, education or regulatory purposes.

          To exercise your PDRP opt-out privilege - or to learn more about the program - visit the AMA Prescribing Data Information Center at www.ama-assn.org/go/prescribingdata. [return to top]

ACP Calls for Physician Review of Performance Ratings before Release

The American College of Physicians has adopted a policy paper outlining principles for physician review of performance ratings—steps the organization believes are necessary to ensure accuracy in those ratings. Among the 11 principles outlined in the paper are the following: physicians should be allowed to review ratings for accuracy prior to public release; payers should provide physicians with a clear explanation of all program facets; payers should have a well-defined and distinct mechanism for responding to physician inquiries; submitting a request for reconsideration should not create an undue administrative burden on physicians; and physicians should be permitted to include comments adjacent to any disputed ratings in the public report. For more information:

Well Point and Aetna Continue to Report Increased Profits

Well Point, Inc, parent company of Anthem Blue Cross Blue Shield of Maine, recently reported increased first quarter profits, due to increased gains in membership.  Net income rose to $1.26 per share or $783.1 million, which is 16% higher than one year ago.

Aetna Inc's first quarter profits rose 8% on increases in premiums, membership and continued cost cutting. The insurer earned $434.6 million or 81 cents a share, up from $401.7 million or 68 cents per share for the same period last year. [return to top]

Anthem to Host 3rd Conference on Healthy Weight May 31

Anthem Blue Cross and Blue Shield will host the third in a series of statewide conferences spotlighting the importance of physical activity and healthy eating to achieve a healthy weight.

Titled Reversing the Tide: Creating a Healthier Maine - The Role of Communities: What we can do to promote physical activity and better nutrition for Maine’s children and adults, the conference will be held at the University of Southern Maine’s Abromson Community Center in Portland on Thursday, May 31 from 8:00 a.m. to 3:15 p.m.

The conference is part of Anthem Blue Cross and Blue Shield’s Health Care Leadership  series.  The May 31 conference is being co-hosted by Let’s Go! - a broad-based community initiative to promote healthy lifestyle choices for children, youth and families in the Greater Portland area

The conference will feature keynote addresses by three of the nation’s leading experts on health, nutrition and fitness:

• Mark Fenton, nationally known walking and pedestrian-friendly communities expert and former host of the PBS TV series “America’s Walking”,
• Margo Wootan, D.Sc., Director of Nutrition Policy at the Center for Science in the Public Interest and director of CSPI’s award-winning 1% Or Less campaign, a community-based nutrition promotion program and
• Christina Economos, PhD,  Tufts University, New Balance Chair in Childhood Nutrition, Friedman School of Nutrition Science and Policy and founder of Shape Up Somerville: Eat Smart Play Hard.

In addition, Dr. Erik Steele, DO, Chief Medical Officer, Eastern Maine Healthcare Systems will give an opening talk on Maine’s current health trends and why change is critical to our future.

Maine faces an emerging crisis that if not addressed will have a profound impact on our state and its health care system in future years. An estimated 61% of Maine adults are overweight or obese and over 36% of Maine children entering kindergarten are overweight or at risk of becoming overweight. Nationally, the prevalence of overweight children has tripled over the past two decades.  Obesity is associated with increased risk for cardiovascular disease, diabetes, and certain forms of cancer, depression, discrimination and weight-related bias. 

This conference will examine what communities can do to stimulate more physical activity in people’s lives and as well as improving dietary choices. Discussion topics will include how to design more walkable and bicycle-friendly physical environments, programs that create healthier school and workplace settings, specific childhood obesity prevention programs, and how to engage all aspects of the community in focusing on the problem and solutions.

In addition to the keynote speakers, the conference will include five in-depth workshops examining specific programs and activities to make our communities healthier and several post-conference field trips. 

Attendees at the May 31 conference will include members from the following fields: public health, health care providers, community activists, service clubs, businesses, educators, state and local government, insurers and the general public. Advance registration is required and the cost of the conference is $30 which includes a healthy lunch. The full conference agenda and on-line registration is available at www.anthem.com/maine/conference. Registration closes on May 18. [return to top]

Study: Physician/Drug Company Ties Still Strong

A study published in the April 26 New England Journal of Medicine examined the ties between physicians and the pharmaceutical industry, and finds that, although a number of initiatives have arisen to separate the two groups, very little has changed in recent years. Researchers conducted a national survey of 3,167 physicians in six specialties during late 2003 and early 2004, and received a response rate of 52 percent. Of respondents, 94 percent reported some type of relationship with drug companies. The most common relationships involved being given food in the workplace (83 percent) and receiving product samples (78 percent.) Respondents also reported receiving reimbursement for meeting and education costs (35 percent), and consulting, giving lectures, or enrolling patients in trials (28 percent). The complete study can be viewed at: http://content.nejm.org/cgi/content/full/356/17/1742 [return to top]

May 4 First Friday Presentation to Feature CMS Quality Reporting Initiative

The May 4 First Friday CME offering will feature presentations on the Medicare Physician Quality Reporting Initiative (PQRI) .  The presenters will include Andrew Finnegan from the Region I CMS office in Boston and Jana Purrell, CPC, Director of the Coding Center.  The PQRI begins on July 1, 2007 and offers the opportunity to enhance Medicare reimbursement by a small amount.

The program will run from 9:00am through noon at the MMA offices in Manchester, Maine.  The cost is $60 which includes breakfast and all course materials.

Anyone interested may register through the MMA website at www.mainemed.com or call 622-3374 and ask for Jess Violette (Press 0). [return to top]