Get ready for all NPI contingencies

May 7, 2007

CMS officials urge pharmacists to get NPI numbers and health plans to develop contingency plans.

Key Points

Less than a month before the implementation deadline for the new National Provider Identifier (NPI) numbers, confusion and concern continue to mount. While still urging all healthcare providers to be ready for the May 23 deadline for using the NPI numbers, the Centers for Medicare & Medicaid Services is urging health plans and others to develop contingency plans.

Recognizing that many healthcare plans and other payers are not ready for the implementation, CMS allowed these companies to develop contingency plans and an extended deadline of May 23, 2008, for full compliance. In a conference call, Karen Trudel of CMS stressed that the new deadline is not an extension and that "noncompliant companies must develop contingency plans, and must terminate the contingency plans as soon as possible." She reported that up to half of the healthcare providers and health plans are not fully prepared to meet the deadline.

Many experts are concerned that the proliferation of contingency plans will only increase the confusion. According to the new CMS guidelines, the agency will not penalize firms for noncompliance as long as they have made "good faith efforts." For those companies, the agency has announced it would accept legacy provider numbers for up to 12 months, "in order to maintain operations and cash flow," said Leslie V. Norwalk, CMS acting administrator.

Movement toward NPI implementation has been beset by myriad problems. In a February letter to secretary of Health & Human Services Michael Leavitt, Simon Cohn, chairman of the National Committee on Vital and Health Statistics, explained that many healthcare providers had not yet received NPI numbers and that many may not obtain them before the deadline.

An even more significant issue has been CMS' delay in releasing its database of NPI numbers. While CMS has insisted that it would release its National Plan/ Provider Enumeration System (NPPES) soon, the delays have forced healthcare providers to contact each of their partners to get their NPI numbers. In the case of large pharmacies, that could require obtaining NPI numbers for every prescribing doctor in the area. In addition, as Cohn explained in his letter, "Many plans need NPPES data to build crosswalks between legacy provider identifiers and NPIs in their own systems to ensure validation of the NPIs given to them by providers and to ensure timely processing of transactions." Without those data, it's been difficult for payers to get the information and adequately test their systems to ensure a smooth transition.

To help respond to the problem, the National Council for Prescription Drug Programs has built its own database of NPI numbers and other healthcare identifiers. According to Cathy Graeff, R.Ph., senior VP of communications and industry relations at NCPDP, its pharmacy database is 75% populated with NPIs for pharmacies and should be at 85% by the May 23 deadline.

Another hurdle has been the difficulty getting providers to share their NPI numbers. To be fully compliant, a pharmacy will have to report its own NPI number on a claim form as well as the number for the prescriber.

"Pharmacies will need to rely on their payer sheets-payers and processors tell pharmacies whether the use of the NPI is required by that health plan/payer," Graeff explained. "We have not yet heard from Medicare Part D what they will allow after May 23. My guess is that the requirements to use the pharmacy NPI will be more likely sooner and the requirement for the prescriber NPIs will be delayed by most if not all plans until they are available."

Experts continue to urge all pharmacies to obtain NPI numbers as soon as possible.

Get it, share it

The Health Insurance Portability & Accountability Act of 1996 mandated the adoption of standard unique identifiers for healthcare providers. The Centers for Medicare & Medicaid Services developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers, known as NPI numbers. Pharmacies that do not already have an NPI should visit the NPPES Web site at http://www.nppes.cms.hhs.gov/. Experts are advising pharmacies to share their number with healthcare providers as well as the National Council for Prescription Drug Programs as soon as they obtain them.