Published 5/1/2007
Steven E. Fisher, MBA

Contingency plan does not eliminate need for NPI

It’s still true: Orthopaedic surgeons, as covered entities (CEs) under the Health Insurance Portability and Accountability Act (HIPAA), are required to have applied for, and received, a National Provider Identifier (NPI) by May 23, 2007.

Even though the Centers for Medicare and Medicaid Services (CMS) has issued a “contingency plan,” the requirement for CEs to have and use an NPI hasn’t changed.

So why have a plan?
Representatives from several large healthcare clearinghouses have expressed serious concerns about an upcoming “train wreck.” Their apprehension reinforces concerns previously raised in a letter from the National Committee on Vital and Health Statistics to the Secretary of the Department of Health and Human Services.

One concern is that many physicians are not testing the use of NPIs. Nor are physicians using the NPI; fewer than 10 percent of the claims currently being processed by the clearinghouses include NPIs. Finally, few payers have built “crosswalks” between current physician identifiers (“legacy provider codes”) and NPIs. These crosswalks are crucial to bridging the gap between standard format and legacy claim adjudication systems.

According to the clearinghouses, unless CMS relented on the deadline, a claims processing meltdown could result, with catastrophic impact on payments to orthopaedic surgeons and other physicians.

What is the plan?
Perhaps as a result of these very publicly expressed concerns, in early April, CMS abruptly announced a contingency plan for implementing the NPI. Very simply, the contingency plan gives CEs (including orthopaedic surgeons) up to an additional 12 months to comply with the rule if they have made a good faith effort to become compliant.

As the contingency plan notes, transactions typically require the participation of two CEs, and noncompliance by one CE may cause the other CE to be noncompliant through no fault of its own. Further, “small health plans” do not have to be in compliance for another year; hence, any transaction between a physician practice and a small health plan is almost certainly to pose compliance challenges for the practice.

Under the contingency plan, CMS will not impose penalties for a 12-month period after May 23 on CEs that deploy contingency plans to ensure the smooth flow of payments if the CEs have “made reasonable and diligent efforts to become compliant.” In the case of physicians, this means, at a minimum, having applied for and received an NPI by May 23, 2007.

It also means that physicians must do whatever they can to engage in testing activities with their trading partners. It is up to each CE to determine the specifics of its own contingency plan. Plans may not extend beyond May 23, 2008, but they may be terminated sooner. Medicare will soon be announcing its own contingency plan.

The enforcement process is complaint-driven. If a complaint is filed against a covered entity, CMS will evaluate the entity’s good faith efforts to comply with the standards and will not impose a penalty on those who have implemented con-tingency plans to ensure that the smooth flow of payment continues.

Steven E. Fisher, MBA, is manager of the practice management group. He can be reached at (847) 384-4331 or sfisher@aaos.org