Bill Gillette

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THE DEADLINE DRAWS NEAR for the healthcare industry to comply with one of the final regulations mandated by the Health Insurance Portability and Accountability Act (HIPAA) in the ongoing industrywide effort to get all arms on the same electronic page. 

May 23, 2007, is the date that's been set for providers to adopt a single National Provider Identifier (NPI), a unique 10-digit numerical identifier that replaces current legacy provider identification numbers. The move was mandated by the Department of Health and Human Services in 1996 when HIPAA became law. The mandate says that by May 23, all providers must obtain and use NPIs for all covered transactions and that all health plans must identify providers by those NPIs. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers. 

For the individual or small-group provider, acquiring the NPI will be a fairly easy process. 

"I got my NPI in about 30 minutes," said Peter Kongstvedt, MD, a practicing internist and senior executive for consulting firm Accenture's Health and Life Science division. "For large provider groups, it's a different story in that it's a much more complex process. Big organizations are likely to get different NPIs for various components-for instance, an organization may apply for one NPI for its nursing-home component, another for its cancer center and so forth. A large organization must also make sure its software for billing, reporting and other functions is in compliance with HIPAA requirements that will link that organization to all payers."  

For plans, says Dr. Kongstvedt, the process may be just as complex. 

"By law, the NPI cannot contain what's known as 'imbedded intelligence,' that is, those parts of the old legacy identifiers that contain certain information-that's gone with NPI," he says. "Another complexity is that many individual providers as well as groups have several ID numbers now-I have more than one, for instance, because I'm licensed to practice in two states-and that will all go away as well. Another complexity plans have to deal with is that the NPI is numerical, while current identifiers are not solely numerical but use letters as well. All this different data has to be gathered and sifted." 

Joel Portice agrees. Portice is founder and chief operating officer of Enclarity Inc., an Aliiso Viejo, Calif.-based software firm that's one of many vendors marketing products targeted at helping both plans and providers comply with the HIPAA-mandated NPI program. 

"There are tremendous challenges to managing this data consistently, and the way data has been collected is wrought with problems," he says. "The real burden of the NPI program rests on the plans, because it's another field that has to be added to their already complex systems." 

Portice says a major problem is the quality of the NPPES data. 

"The nature and quality of the NPPES are limited and lacking," he says. "The challenge is to link to and match all of this data in the payer's system. This is not a trivial event-payers will have to bring all this information together and make sure it's accurate and organized." 

Articles

The deadline draws near for the healthcare industry to comply with one of the final regulations mandated by the Health Insurance Portability and Accountability Act (HIPAA) in the ongoing industrywide effort to get all arms on the same electronic page.

For whom the NPI tolls: Deadline for HIPAA compliance closes in

Paul Handel, MD, has enjoyed a long, distinguished career as a physician in Texas, and now he wears two distinctive hats-neither of which is a Stetson. 

"I don't know of any other state association that has a doctor on its board who's also an officer of a carrier," he says. "I also don't know of a carrier anywhere in the country that has an officer who's also on the board of a state association. I do know that the past couple of years with the TMA and BCBSTX have been the most rewarding and exciting of my career." 

A board-certified urologist, Dr. Handel ran a successful private practice in Houston and was a clinical professor of surgery at the University of Texas Health Science Center Medical School. A graduate of the University of Texas Medical Branch in Galveston, Dr. Handel's career has earned him recognition on both state and national levels. 

Q. As a board member of the TMA and chief medical officer of BCBSTX, you have a unique perspective on both the provider and payer sides of the fence. How would you characterize today's relationship between payer and provider?

At BCBSTX, we're including physicians in the creation of policies and procedures-that's key. For example, as we begin to look at pay-for performance and other evaluation measurements, we begin to see the real picture of what physicians are all about, and we're working with them to help us develop the metrics by which they'll be measured and evaluated-and that goes for the inclusion of patients, too. Believe it or not, this kind of inclusion has only recently begun happening in the healthcare industry.  

Medicine has evolved to a point of a lot more communication and education of this kind. We're truly at the beginning of the process-and a lot more communication and education is needed. 

Q. Along those same lines, how thin a wire do you walk in advocating for providers as a TMA board member and for payers in your role with BSBSTX? What are the advantages of being on both sides of the table? The disadvantages?

 Not long ago I met with a physicians group, and one of them asked me what my position was with BCBSTX. I kiddingly-maybe half-kiddingly-replied that I'm the  piñata-I take the knocks on both sides. I've been accused of taking the TMA position by BCBSTX and the BCBSTX position by TMA. 

Paul Handel, MD, has enjoyed a long, distinguished career as a physician in Texas, and now he wears two distinctive hats-neither of which is a Stetson.

Between physicians and payers: Physician executive in dual role seeks to build trust

Healthcare professionals begin to realize benefits of mobility and instant access

Handhelds gain foothold among immediacy oriented providers

When Jeff Miles stepped into the presidency of the California Association of Health Underwriters (CAHU) last July, he also stepped directly into a political storm. The financially strapped state's electorate was about to recall former Gov. Gray Davis and later elect the action-hero-turned-activist Arnold Schwarzenegger.

Author | Bill Gillette

Articles

For whom the NPI tolls: Deadline for HIPAA compliance closes in

Between physicians and payers: Physician executive in dual role seeks to build trust

Handhelds gain foothold among immediacy oriented providers

California by storm