Viewpoint: Top Five NPI Myths

National Provider Identifier (NPI) compliance is driving significant system and business process changes. The consequences of not properly planning for NPI are far-reaching, including delayed claims payment, unhappy providers and potential disruptions to mission-critical processes.

Here's a look at several common misconceptions about NPI, and how health plans can be sure they're taking the right steps toward compliance, while enabling more effective provider network management across their organizations.

Myth 1 - NPI compliance is an IT project with a deadline.

A lot of emphasis on solving the NPI problem has been focused on IT projects for compliance of HIPAA-covered transactions. Transitioning to using NPI goes beyond the scope of IT and will resonate long after the May 23, 2007, compliance deadline.

Health plans that have successfully addressed the NPI challenge have approached it from an enterprise-wide perspective – engaging both IT and business teams in the discussion. The impact of NPI can be significant – expanding beyond claims administration to credentialing, member enrollment and even medical management.

For long-term success, health plans need an infrastructure that's capable of processing NPI-based claims in a dynamic environment, as more regulations and requirements are likely to arise. Changes in the provider environment will also require long-term NPI maintenance, such as adjustments to provider NPI status, further sub-parting beyond existing design, consolidation of sub parts, and changes in provider organizations that will drive modifications of NPIs and impact the relationships to legacy IDs. Additionally, changes to payer systems and workflow processes caused by mergers and acquisitions, technology advancements, and new member offerings will present new challenges.

Myth 2 - NPPES is a reliable source for acquiring NPI.

National Plan and Provider Enumeration System (NPPES) is the system set up by the Centers for Medicare and Medicaid Services (CMS) to issue NPIs. However, CMS has not yet outlined how payers can retrieve NPIs from NPPES, delaying the industry in obtaining the new identifiers.  As a result, health payers must look beyond NPPES as they determine the best approach for capturing NPIs, introducing the identifiers into their legacy systems, and verifying provider NPIs.

Health plans can expect NPIs to be exchanged in different formats, and will have to tap NPPES to verify that an NPI was issued. But the responsibility of matching NPIs to existing data and validating the integrity of an NPI will fall on health plans.

Myth 3 - NPI mapping challenges can be alleviated by business changes.

Extremely complex relationships exist between NPI and legacy identifiers. Legacy systems use various "hard coding" techniques that are provider-number-specific, and NPI contains no such embedded intelligence. Health plans really have two options: modify their applications to function with NPI, or use a proprietary identifier obtained through an NPI crosswalk.

At the heart of the NPI issue is the need to match NPIs to existing business relationships, represented by provider demographic data and existing legacy PINs. The process of linking NPIs to relationship data is called matching. But matching isn't enough. In order for a crosswalk to be successful, health plans need to be able to translate the provider relationship data, which is then matched to NPIs.

Health plans need to consider the embedded logic in their legacy PINs, and how this determines which data elements are required by a crosswalk to translate NPIs to PINs. Much attention is given to the most common matching scenarios where the matching can be done one-to-one. The challenge comes when the scenarios are more complex: one-to-many or many-to-one.

Adjusting existing business processes isn't enough. Proactive health plans realize the importance of reaching out to healthcare organizations to understand their approach to enumeration in order to determine how to structure crosswalks to accommodate complex scenarios.

Myth 4 - NPI Compliance is an EDI claims and remittance issue.

As many business processes across the enterprise will be impacted by the introduction of NPIs into the payer system, an NPI solution needs to look beyond claims and remittance.

NPIs will also be included in other HIPAA-covered transactions. Transactions 837 and 835 are the most critical, but health plans need to address other transactions such as 270/271, 834, and NCPDP.

Most health plans are implementing crosswalks to allow existing systems to request a translation of an NPI to the appropriate PIN. Systems making that request include enrollment, membership, customer service, portals, medical management, and EDI gateways, to name a few. These systems are necessary for supporting functions and business processes for membership services, care management, claims operations, performance management, electronic services and IT management.

Myth 5 - NPI crosswalks are straightforward technical solutions.

While many payers have extensive resources, expertise and experience configuring solutions for HIPAA requirements, the complexity of NPI is different from previous HIPAA regulations and requires a more sophisticated solution.

NPI is different because creating a crosswalk between identifiers is not a sufficient solution; the real challenge is to create a translation between the NPI and the existing PIN relationships. Any NPI crosswalk solution requires a repository that is capable of dynamic matching; a static set of tables cannot handle the complexity of this type of matching.

Crosswalk performance and availability will be critical, given the volume of requests and the need to minimize any impact to existing narrow processing windows. Around-the-clock availability with minimal downtime is crucial in order to prevent bottlenecks during peak processing hours.


The building blocks for a successful approach to NPI compliance must include components that address the exchanging of NPIs, the matching of NPIs to existing provider relationship data, the storage of complex provider data, the performance requirements of an NPI crosswalk, and the ongoing maintenance and analysis of NPI crosswalks to ensure accuracy and long-term benefits.

Sam Muppalla is COO at Portico Systems, a leader in provider network management solutions.

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