Motivation – Poor Provider’s Data Quality
The provider’s demographic data is dynamic by nature. Providers move their offices, add facilities, change their phone numbers, are sanctioned and stop practicing. Poor healthcare provider’s data quality affects virtually every aspect of healthcare payer’s enterprise, diluting profits and member goodwill. Their applications, interfaces, databases, files and reports currently use legacy provider identifiers. Provider data often exists in not one but many disparate databases throughout a healthcare payer’s IT enterprise, including multiple variations of the same provider record. Provider’s variations and discrepancies generate as much as 12 percent of physicians checks returned, raise numbers of support calls, increase manual claim adjudication, and impede identification of billing fraud and abuse. For instance, the cost of single check re-issue alone can reach $20 for opening/handling, researching the correct provider, reissuing and mailing the check.
Opportunity – HIPAA
The 1996 Health Insurance Portability and Accountability Act (HIPAA) established national privacy and security standards for electronic health care transactions, including a national identifier for providers, health plans and employers. Accordingly, by May 23, 2007, health care providers and all health plans and clearinghouses must change both their processes and information systems to implement HIPAA’s National Provider Identifier (NPI) regulations.
Successful transition to NPI is critical to every aspect of operations and impacts eligibility and authorization processing, provider enrollment, contracts and directories, claims adjudication and payment, referrals, and reporting. It
- Simplifies communication and administration
- Facilitates efficient electronic transmission of health information
- Streamlines detection of billing fraud and abuse
- Improves debt collection efforts
- Reduces cost to re-issue checks
- Improves accuracy of provider directories and reduces support cost
- Reduces cost of claim adjudication – the cost of auto-adjudicated claim is $.40, 10-fold less than a manually adjudicated claim.
Means – NPI
- A unique 10-digit identification number
- Assigned for life to a provider and de-activated only upon death, retirement, or identity theft
- Replaces multiple legacy provider identification numbers, including Medicare UPINs, commercial payer Ids, and state Medicaid IDs
- Independent of key provider information changes, such as practice location or specialty
- Clean – Create good provider’s records by reconciling, standardizing, augmenting and integrating legacy provider data.
- Crosswalk – Build a crosswalk between NPI and legacy provider identifiers. Since many providers have multiple locations and affiliations, the crosswalk of NPIs to legacy provider identifiers used in different provider files might be a complex one-to-many mapping.
- Maintain – Actively manage and clean provider data records as they change in the future.