April 28, 2005
The Honorable Michael O. Leavitt
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Washington, DC 20201
Dear Secretary Leavitt:
The undersigned organizations would like to voice our concern regarding the implementation of the National Provider Identifier (NPI). It is critical that the government, in concert with the health care community, develop a comprehensive implementation and outreach strategy in order to avoid unnecessary costs, delays, and disruptions.
As we prepare to move forward with this federal mandate, our goal is to ensure smooth progress toward implementation and effective use of resources as implementation proceeds. We believe that a successful, cost-effective, and timely implementation of the NPI is achievable. There remains a great deal of confusion surrounding when and how the NPI will be implemented and we urge increased communication and guidance from the government.
We gratefully acknowledge and appreciate the time and support we have received from the Centers for Medicare and Medicaid Services (CMS) staff on NPI issues. However, to help ensure cost-effective, timely implementation, we seek an increased level of collaboration and interaction between the government and the health care community.
While we understand that an official response to the Workgroup for Electronic Data Interchange (WEDI) Sept. 2004 recommendations is being developed, it is important that CMS quickly address critical NPI issues. The WEDI recommendations make it clear that strong management, effective communication, and staged deployment are necessary for all national EDI standards. Combining this leadership with substantial coordination between the various stakeholders will help reduce costs associated with uncertainty and differences in implementation schedules between trading partners.
To improve the NPI deployment process, please consider the attached recommendations. An overview of the six recommendations supported by the undersigned follows, and there is a strong consensus that, when taken collectively, these recommendations should improve and ease the burden associated with the NPI implementation process:
The transition from the current system of proprietary provider numbers to the NPI will be expensive for all health care organizations. In these times of escalating health care costs, our nation cannot afford to repeat the experience of the HIPAA Transactions and Code Sets (TCS) implementation with its high level of uncertainty, protracted deployment, and excessive costs. We believe these proposals will provide a more cost-effective transition toward NPI implementation and will avoid the potential confusion that could result from the current NPI implementation approach.
We appreciate your willingness to consider these consensus recommendations and look forward to a productive dialog with the federal government on this important matter.
Very truly yours,
American Academy of Dermatology Association
American Academy of Facial, Plastic and Reconstructive Surgery
American Academy of Family Physicians
American Academy of Neurology
American Academy of Ophthalmology
American Academy of Otolaryngic Allergy
American Academy of Otolaryngology - Head and Neck Surgery
American Academy of Sleep Medicine
American Association of Clinical Urologists
American Association of Healthcare Administrative Management
American Association of Neurological Surgeons
American Association of Orthopaedic Surgeons
American College of Cardiology
American College of Chest Physicians
American College of Emergency Physicians
American College of Gastroenterology
American College of Obstetricians and Gynecologists
American College of Osteopathic Family Physicians
American College of Osteopathic Surgeons
American College of Physicians
American College of Radiology Association
American College of Rheumatology
American College of Surgeons
American Gastroenterological Association
American Geriatrics Society
American Health Care Association
American Hospital Association
American Medical Association
American Medical Group Association
American Osteopathic Academy of Orthopedics
American Osteopathic Association
American Society for Gastrointestinal Endoscopy
American Society for Reproductive Medicine
American Society for Therapeutic Radiology and Oncology
American Society of Addiction Medicine
American Society of Anesthesiologists
American Society of Cataract and Refractive Surgery
American Society of General Surgeons
American Society of Nephrology
American Thoracic Society
American Urological Association
Association of American Medical Colleges
Child Neurology Society
Congress of Neurological Surgeons
Delta Dental Plans Association
Infectious Diseases Society of America
Laboratory Corporation of America Holdings
Medical Group Management Association
National Electronic Attachments, Inc
North American Spine Society
Public Health Data Standards Consortium
Renal Physicians Association
Southern Healthcare Administrative Regional Process
Society for Cardiovascular Angiography and Interventions
Mark McClellan, MD, PhD
Administrator, Centers for Medicare & Medicaid Services
Simon Cohn, MD, MPH
Chair, National Committee on Vital and Health Statistics
Jeffrey Blair, MBA
Co-Chair, NCVHS Subcommittee on Standards and Security
Co-Chair, NCVHS Subcommittee on Standards and Security
Director, CMS Office of HIPAA Standards
Acting Director, Provider and Supplier Enrollment, CMS
James Schuping, CAE
Executive Vice President/CEO, Workgroup for Electronic Data Interchange
Health care Industry Coalition Letter on NPI Implementation Process
Recommendation / Issue # 1
Authoritative Single Point of Contact - Leadership of NPI
As NPI implementation moves forward communication channels among the affected stakeholders must be well coordinated. Establishing an ongoing dialogue will help ensure that as decisions are made the appropriate message is communicated. To help with the communication dialogue, we recommend the following:
The CMS Role
CMS' Office of HIPAA Standards must provide clear leadership in this initiative and establish the necessary dialogue with all of the affected stakeholders. To achieve this goal it is important to appoint an individual with the necessary authority to do the following:
Health care Industry Coalition Letter on NPI Implementation Process Recommendation / Issue # 2
National Plan and Provider Enumeration System (NPPES)
Industry knowledge of what to expect from the enumeration process is an integral piece to the implementation of the NPI.
The industry has identified specific issues for which clear guidance must be provided in order for successful industry implementation to occur:
Industry stakeholders are struggling with their planning activities, such as gap analysis and design, because too many outstanding questions remain. Without specific answers to many of these questions, stakeholders are unable to move their projects along or they are forced to make broader assumptions about the amount of information that will be available. These issues ultimately affect the efficiency of the implementation planning process. Projects are either pushed off to a date much closer to the mandated deadlines - thus decreasing the transition time periods - or the projects over build capability and handling - causing drastic and costly changes in the direction of new information systems design.
CMS should: 1) Remove many of the unknowns by providing answers to the above questions as quickly as possible. 2) Seek collaboration with industry stakeholders so that all aspects and potential impacts are readily identified and resolved. 3) Continue to work on additional issues and questions that arise on the data needs and enumeration schema. Clearer and timely communication between CMS and the health care community will make the likelihood of successful implementation greater. Tackling many of the unresolved issues quickly will enable the industry to move forward and address some of the other global issues such as education and transition time frames as some of the detailed information is necessary to proceed.
In addition, CMS should expedite Medicare's payer readiness, including systems modifications, contractor instruction/direction, and provider notification, for NPI acceptance and take a leadership role with respect to the readiness of State Medicaid plans, including coordination of when their systems modifications, standard enumeration of non-health providers and provider notification are completed. This would insure timeliness in implementing NPI acceptance.
Health care Industry Coalition Letter on NPI Implementation Process Recommendation / Issue # 3
National Coordinated NPI Outreach and Communication Initiative
The health care organizations represented in this letter are prepared to work together with CMS to develop and manage a coordinated national initiative to support the effective dissemination of NPI information. We recommend that WEDI be asked to serve as the lead in coordinating a council of health care leaders to work with CMS to develop national educational/outreach approaches for NPI implementation.
The core elements of an effective coordination of national efforts, include:
We recognize that many organizations will be independently involved in the overall effort, both at the national level as well as at the local and regional level. However, it is vital that there be 1) a consistent message and clear sources for definitive information; and 2) a strategy for delivery coordination to minimize wasteful overlap, and to make sure adequate resources are targeted to all affected industry stakeholders.
The CMS Role
CMS should provide leadership in the development of NPI material and review of content developed by others and provide national and regional NPI speakers to augment or support local educational and outreach efforts.
In developing training materials, CMS should consider incorporating results from pilot testing efforts and the lessons learned. CMS should support appropriate Web tools including Q&A sections and conduct various audio cast programs.
Health care Industry Coalition Letter on NPI Implementation Process Recommendation / Issue # 4
Coordinated NPI Deployment Approach with Defined Implementation Milestones
Establishing a coordinated approach with clearly defined phases and timelines, as proposed by the WEDI PAG in May 2004, will significantly lower implementation costs and cause fewer disruptions to the processing of claim transactions.
Staging NPI implementation based on the following timeline would alleviate much of today's confusion and would reduce the transition costs for implementation among all entities.
Stage I - May 23, 2005 to 1st Quarter 2006
Stage II - 2nd Quarter 2006 and forward
Stage III - 3rd Quarter 2006 through May 23, 2007
Stage IV May 23, 2007 and beyond
We believe the stages outlined above represent an acceptable timeline for orchestrating the transition to NPI. We would encourage all of the federal agencies to adopt this staged approach. This would streamline efforts toward NPI implementation and would avoid potential confusion with the current NPI approach.
CMS should adopt this timeline for sequencing implementation of NPI and provide periodic progress reports on the conversion process. CMS should also assess the progress made against the designated timelines above and adjust accordingly if events fail to achieve their stated objectives. Finally, CMS should serve as a single point of information for all government programs regarding NPI deployment.
Health care Industry Coalition Letter on NPI Implementation Process Recommendation / Issue # 5
Coordination of NPI with other Related Transaction, Codes and Identifiers
There are other direct and indirect HIPAA transaction changes that are forthcoming such as claims attachments regulation, the e-prescribing regulation, and the health plan identifier regulation. There are a number of questions on how these changes will impact system designs currently being planned for the NPI. For instance, it would be very helpful to clarify subpart definitions so that system vendors or system maintainers can decide on how best they should approach these upcoming changes.
Below are some issues and recommendations for consideration:
To maximize the value and impact of the NPI effort in relationship to other HIPAA TCS changes on the horizon, CMS should consider the following:
Health care Industry Coalition Letter on NPI Implementation Process Recommendation / Issue # 6
Use of NPI - Paper and EDI Format Exchanges
Currently, the NPI rule targets the handling of NPI for HIPAA TCS, however, there are cost savings that could be achieved if paper and electronic formats could approach the use of the NPI in the same manner.
The industry is concerned about spending precious health care system resources to build and maintain claims systems that process with both the legacy identifiers and the NPI. Unless we can all agree to use the NPI in all applicable processes, the payers and providers in particular, will never be able to discontinue the maintenance of legacy identifier systems when not necessary.
Small, independent providers have been the slowest segment to adopt EDI practices. For example, in the dental industry, which consists mostly of small practices, less than 50% of claims are submitted electronically. Requiring no changes to current practices will further delay the move to EDI. Allowing continued use of legacy identifiers on paper forms, while requiring a provider to apply for an NPI to do EDI creates a disincentive for EDI adoption. Also, if providers were already using the NPI, there would be one less adjustment to make as they adopt a new practice management system or clearinghouse relationships that support EDI transactions.
Confusion and processing delays will occur if legacy identifiers are allowed for paper, while the respective EDI transactions use NPIs. It will be difficult to switch between EDI and paper in the middle of a complicated claims process such as Coordination of Benefits (COB) between payers and claims requiring attachments. The potential for misdirection or delay of a claim due to dual identifier use is real. The HIPAA-named NCPDP 5.1 transaction and 276/277 claim inquiry/response transactions cannot support both the NPI and the legacy identifiers, so providers might not know which number to use and may experience difficulty tracking the status of such claims.
Adopting the following recommendations would alleviate some of the confusion and optimize the transition costs for implementation.
While we understand that the law does not allow CMS to mandate use of the NPI on paper submissions as a HIPAA requirement CMS can however, play a leadership role in the encouragement of NPI use on paper forms for Medicare participating providers.
Finally, CMS should make every effort to document its agreement and support for the use of NPI on paper forms with: