First Look: CMS NPI Crosswalk Logic and IRS Change Impacts

Yesterday we posted the first public glimpse of the logic that Medicare is using to map incoming claims against providers NPPES (NPI) records to find matching Medicare PECOS (enrollment) records.  If you missed it, you can download the spreadsheet here:

MatchingRecipesWithCounts05_27_08.xls 

We also published an analysis of what CMS's new warning about NPPES/IRS mismatches might mean to providers who thought they were safe (see CMS Adds IRS Domino to Tumbling NPI Data). If you get a letter from CMS, will the changes they force you to make create a problem that requires an 855 enrollment (PECOS) update? If so, it could result in months of suspended claims.

The crosswalk file gives us a clue, especially since it gives daily counts of which rules are firing.

I did a quick analysis, where I segregated the organizational rules from the individual rules, and used the spreadsheets own matching statistics to measure the proportional impact.  You can download it here: Download CrosswalkMatchAnalysis.xls... continue reading the article >>
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Posted Jun 12 2008, 12:30 pm

Grant Roundup for June, 2008

• Health Care Foundations Unveil $4.5 Million Program

• Lawmakers Push for Passage of Health Care IT Legislation

• Microsoft Awards $4.5M in Grants to 15 HealthVault Projects

• Hospital Tax Breaks Smacked in Health Reform Hearing

• Pittsburgh Insurer To Provide $29M To Help Physicians Adopt IT

• Washington Health Information Technology Grants

• Highmark Moves On HIT Funding for Physicians

• HHS Chooses Areas Where Doctors Get Paid for Using EHRs

• Health Plan Gets Prestigious Grant To Evaluate Physician Incentives

• HHS: Grants for Public Health Preparedness

• AHRQ Health Information Technology Programs Update

• $1.3 Million to Improve Medical Device Use & HIT

Are We Profiting from NPI SNAFU?

(This is the post where we publish the Medicare NPI Crosswalk. SHHH! Don't tell....)

You might have noticed that we often slip in little advertisements, and occasionally even in-line mentions, of our products and services in these web posts.  You know, for the Provider Taxonomy webinar, or the NPI Contingency Status Survey report, or, heck, even the HIT Grant Resources Directory for nonprofit fundraising.

Could it be, as we were once accused, that we are roiling up a false problem so that we can exploit it for financial gain?

How can I answer that charge in an appropriately professional manner?

No.

This Is Where We Prove Our Point
To prove just how bad we are at exploiting our arcane expertise for personal gain, I'm going to share something that just came over the transom.  I haven't even had time to look at it very thoroughly myself, but it sure as heck looks like that long-anticipated Medicare NPI Crosswalk logic I've been railing about for months.  You know, the thing that tells you how the field-by-field comparisons work, so you can figure out how to update your NPPES/NPI record and/or your PECOS enrollment data and/or your claims data to get paid.

Guess how much we're going to charge you for it?

That's right. Nothing. Download it here. MatchingRecipesWithCounts05_27_08.xls 

And at this moment I have no idea whether this is the complete set of matching algorithms, or if they apply to Part A, Part B, or both. Looks pretty up to date, though, because one column includes stats of how many matches were logged against each rule on May 27. (And I should mention that, at first glance, it doesn't look nearly as brain-dead as I suspected, after all the provider horror stories. Wonder why they wouldn't want to publish it?)

Will Work for Wheel Bearings
Meanwhile, we could really use a quickly-executed, short-term, no-fuss consulting contract. We have immediate availability and the HITmobile is in desperate need of some front-end work. Gather up all my relevant contact information here and send me a note or give me a call. Will travel (by air or rent-a-car) or consult from our opulent offices overlooking South Tulsa as you prefer. First come, first served. Your mileage may vary.
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Posted Jun 11 2008, 4:09 pm

CMS Adds IRS Domino to Tumbling NPI Data

Back in the day, I used to believe that everyone in this industry was operating with the best of intentions.

Increasingly, though, I am starting to side with the most cynical of my provider colleagues who think that Medicare just doesn't want to pay claims.

Even as the Department's non-compliant, non-transparent NPI edits are quietly snarling claims all over the US, they have added a new flaming hoop to the race course: Your NPPES (NPI) data must not only match your OSCAR (Medicare enrollment) record, it must also match what the IRS has listed -- somewhere -- as your legal business name.(LBN)  Here's what the notice says, and here are the staggering implications... continue reading the article >>
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Posted Jun 11 2008, 7:59 am

Solutions for the Top 3 NPI Rejections

Thanks to Jose Luis Gonzalez at ANCO  for posting a link to this document by Medicare carrier NHIC, which lists their top 3 NPI errors and how to solve them. Interestingly, the solutions generally seem to indicate a "less is more" approach -- take stuff out to get the claim through.

The one-pager is remarkably succinct and actionable. A good example of the kind of transparency we've been advocating CMS adopt house-wide. Though NHIC's tidy little message falls far short of a full explanation of how Medicare is crosswalking claims data to PECOS data, it should provide a good guide for providers encountering the edits they list (M402, M417 and M419; M381 and M379, respectively)

NPI Rejection Rates Not the Whole Story

Medicare shoots out one carefully-worded story and it starts bouncing around the echosphere: Our Experts Agree, Everything Is Fine. This version comes from the HFMA website: "most of the Medicare contractors [are] reporting that over 90 percent of claims are NPI-compliant." We immediately posted our response, which said, basically, that "NPI-compliant" was a meaningless term, since it didn't address whether the claims would be properly crosswalked or paid, and that even 10% was an awful lot of rejections, when it comes to Medicare.

But in absence of any real news (like real adjudication rates, real payment levels, etc.) from Medicare, the story keeps bouncing around the HIT world.

Okay, here's some news, folks.  Taken directly from CMS's own statistics, using a "per business day" calculation based on 251 working (and billing) days per year against unadjusted 2006 numbers.

• 10% of daily Medicare claims means that 386,853 claims are bouncing every day.
• 10% of daily Medicare payments means that providers are going unpaid to the tune of $149 million every day.
• Today is the 10th business day since May 23.  Do the math: 4 million claims, $1.5 billion dollars.

Here's the other news: Medicare's numbers are grossly underestimating the problem.
Why?... continue reading the article >>
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Posted Jun 5 2008, 11:06 am

Reader: MM5980 Still (Mostly) On

Yesterday, an alert reader caught the notice that CMS had recinded MM5980, the Medlearn Matters article that told Medicare providers they need to violate HIPAA by plugging in their own NPI when a secondary provider (Referring, Ordering, Attending, etc.) did not have an NPI. (See Is Medicare Backing Off Noncompliant NPI Strategy?)

Now, an even more alert (or perhaps well-connected) reader, let's give her the code name Mrs. Plame-Wilson, says somebody inside CMS told her it's just a content-related error that prompted the memo to be withdrawn. The rules haven't changed since Medicare changed them. Don't worry, you can still add the spaghetti code to do that noncompliant kluge that will get your claim past our edits. (I'm paraphrasing here, to protect my source's Covert Ops status.)

In other words, "We're still going to violate HIPAA." ... continue reading the article >>
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Posted Jun 4 2008, 6:00 pm