The National Provider Identifier was defined as part of HIPAA Administrative Simplification with the
goal of creating a unique provider identifier that could be used nationally across enterprises as the only identifier
for all provider entities. The assumption is that when there is a single unique and universal identifier for providers,
then the administrative burden for provider, payers, clearinghouses, and other health care stakeholders will be dramatically reduced.
Though all healthcare providers will be eligible to receive NPIs, covered healthcare entities will be mandated to use the NPI
as the sole provider identifier in all HIPAA electronic transactions. The 10-digit number will be assigned by a CMS-funded NPI “Enumerator”
through the NPPES (National Provider and Plan Enumeration System).
Unfortunately, today there are a large number of identifiers used to identify providers.
These provider identifiers form the heart of the healthcare reimbursement structure and systems,
successful implementation of the NPI within provider and payer organization is crucial to maintaining cash flow and financial health.
These identifiers are used for contracting relationships, their associations with other business providers, and many other business attributes.
The transition from today’s environment to that envisioned by Administrative Simplification will not be that simple.
Edifecs CrossWalk Solutions Approach
Individual healthcare entities and the healthcare industry as a whole are researching several implementation strategies for NPI.
The basic fact common to all solutions is that while the NPI identifies the correct provider,
it does not provide enough context to determine the reimbursement contract such as procedure codes, taxonomy codes, address, place of service, etc..
What is required is either additional information or a development effort which adds logic to match the provider identifier,
along with additional fields to determine the correct context and reimbursement contract.
In the long run it is expected that this logic will eventually become part of the payer and provider back-end systems,
but in the near term a transition solution can be created using a front-end crosswalk mechanism.
Another approach the industry has examined has included using situation fields in the transactions to pass along the necessary context,
but this has been deemed to further complicate the NPI challenge. The industry for the most part is coalescing around adding this logic
to their back-end adjudication, PMS, or HIS system with the help of their software vendors.
At the same time the industry is putting into place a transition solution using front-end crosswalk to keep claim
and transactions processing at the current automated rates.
So what will this front-end system look like and how will work? In summary, the front-end system will process data at the edge of organizations
IT system as the data enters or leaves the organization. The back-end system will continue to work as it currently works.
The front-end system will ensure that the data entering the organization and going into the back-end system gets changed to meet
the needs of the back-end system. Similarly as the data from back-end system is ready to leave the organization,
the front-end system will change the data so the trading partner’s system will receive it with the necessary NPI information.
The front-end system is conceptually fairly straightforward to understand and it is an appealing transition solution because
the back-end systems are not impacted. However, the implementation of a front-end system along with the logic needed for
it is not a trivial task. The front-end system must be comprehensive, flexible, robust, and scalable to meet industry needs
without adding another step into an already complex and breakable process.
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