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Providers Facing Identity Crisis as NPI Vexes Claims Processing
By Martin Jensen
Hospitals, labs, clinics and physician practices large and small are used to the "flaming hoop" cycle — slicing and dicing the data each government and private health plan wants to see in order to get paid. The regulations enacted under HIPAA to establish a single National Provider Identifier were designed to correct a small but critical component of that: replacing the various payer-controlled identification systems with a single, universal numbering system that all payers would have to adopt, discarding all the state-specific Medicaid numbers, the half-dozen or more Medicare numbering systems, and various governmental and payer-specific legacy IDs.
The rule was that individual providers (i.e. human beings — doctors, nurses, physician assistants and the like) could obtain only a single number which would identify them in all contexts. Organizational providers could obtain one or more identifiers as they saw fit, based on identifiable differences like location and care setting (acute inpatient hospital vs. rehab unit vs. outpatient surgery) and their own self-determined business requirements. Payers were specifically enjoined from telling providers how to enumerate.
But when the May 23, 2007 deadline approached, it was clear that, as usual, the industry was "unprepared" for the cutover. Providers weren’t ready to walk on their NPI legs and payers weren’t ready to drop their legacy ID crutches. Regulators at the Centers for Medicare and Medicaid Services (CMS) announced a one-year contingency period and CMS’s own Medicare division quickly adopted a phased contingency plan. First they would require billers to submit their own NPIs in combination with legacy IDs, then gradually wean them off to the mandated "NPI only" transactions. The critical issue of how to represent all of the other providers on the claims (such as the referring provider on a radiology claim, or the ordering physician on a lab claim) was left for a last-minute, untested cutover for May 23, 2008.
CMS, as usual, blamed the perennially unprepared providers for the delay. But the true culprits may lie a bit closer to home. Medicare, in what observers saw as direct violation of the regulation, issued a thinly-veiled threat (warning: PDF) to its providers to obtain NPIs according to their existing suite of Medicare numbers.
This wasn’t just a fairness issue. It was tantamount to an admission that Medicare was not gearing to deal with the post-NPI world of provider-determined identification schema. They also set an unhealthy precedent for other payers, including a number of state Medicaid plans, who subsequently communicated their own "expectations."
"If Medicare can tell them how to enumerate, why can’t we?"
Well, how about, because if providers use one numbering system for Medicare and another numbering system for you, the claims which list both organizations as payers (many millions per day) will break down for lack of a consistent identifier? One ID per claim sort of requires that everyone use a common number, does it not?
The initial spike in claim rejections was startling, even to those familiar with the reports that some early adopters had gone unpaid for months. According to one source, Medicare rejections spiked by a factor of four, while Medicaid denials went up six-fold and Blue Cross rejections doubled.
Many of the problems have certainly settled out as providers regrouped for the new line of flaming hoops. But just as things seemed calmer, CMS imposed a new requirement: Employer Identification Numbers and Legal Business Names on NPI records needed to match an unnamed IRS data source or the NPI would be de-activated. While there was no recognition that such a change might trigger a mismatch downstream, our analysis indicates that virtually all of Medicare’s crosswalk logic relies on EIN, and nearly half of the matching goes against all or part of LBN. What’s more, secondary changes required on the Medicare side could, again, leave those claims unpaid for months, thanks to well-documented bureaucratic delays.
Catch more of our ongoing NPI coverage at the HIT Transition weblog.
It’s Time to Wake Up …
By Recruit Guy
In the realm of HIT, healthcare is unique. Healthcare is not unique. We have become so engrained that healthcare is a totally “different animal” with its own idiosyncrasies that we have totally ignored the advances and expanded maturity levels that exists in other industries. Sure, the clinical process is specialized and requires experienced trained clinicians and healthcare professionals to design and support advanced clinicals that support the care process. However, there are two broad general areas critical to any health delivery organization where we have not leveraged the advances and maturity levels that have been achieved in other industries.
The first area is often referred to as ERP that cover areas such as Supply Chain (Materials/Purchasing), HR, EDI, Accounting/Budgeting, etc. We are experiencing a severe shortage of capable practitioners that have experience in specific HIS solutions. The critical distinction here is differentiating between specialized clinical and reimbursement or revenue cycle application areas of I.T. and the other areas dealing with ERP applications. The shortages are not so much anchored around the lack of process expertise. The shortage relates to training and certification specific to the solutions (i.e. Cerner, Epic, Meditech, etc). The only way to expand or grow these qualified resources are to receive the build and design training associated with a client contract and play a principle role in the implementation project. This creates a very closed and restrictive supply of experienced professionals that very quickly join the ranks of consultants and installers that leave the provider organizations and join consulting organizations and go from project to project. These exits create an even greater shortage overall so we constantly have one organization stealing from another with many going to the highest bidder. Why exacerbate this phenomenon with the non-clinical HIS modules and applications for which there is greater expertise and functionality outside the traditional HIS solution sets?
The second area deals with technology infrastructure. Technical infrastructure is comprised of areas such as network and system architecture and processes that support the best practice components of ITIL (Service Support and Service Delivery). This expertise more abundantly exists in other industries in areas that are truly generic between healthcare and other industry environments and are substantially more advanced than healthcare.
Recruiting experienced personnel out of these mature and established industries achieves a much greater value for our organizations. Granted, a redesign of the departmental I.T. structure may be needed to align in the manner outlined. This model pushes the clinical application expertise more into the user departments that relate to clinical and revenue cycle processes. I’ve always been a proponent of this model because it fosters greater ownership and responsibility within these user departments.
Wake up healthcare. Let’s quit thinking we’re so unique in areas where we’re not and let’s join the big league. This massive amount of in-breeding has caused greater costs for less quality and we’ve created a treadmill we can’t seem to dismount.
Girls’ vs. Boys’ Clubs
Ms. DeBell’s post on women moving higher into the IT ranks brought to mind a recent conversation I had with a candidate with whom I am working. For those that are unfamiliar, I recruit in the HIS field (five years). I thought some of the points of the conversation would be worth sharing. It may also help the perpetually offended to wad their panties. I promise to not refer to myself in the third person (we love you, TPD).
I called this fellow while working for one of his company’s local competitors. He returned my call months after I placed someone. For several reasons, the time had come to move on, not the least of which was the recent promotion (over him) of someone with lesser skills, but a master’s degree. His goal now is to complete either a MS/MIS or MHA.
This fellow had been in a variety of roles, including management (hospital administration, not IT), and he felt that IT need not be his only option. He asked what I thought about widening his options. I began with the usual disclaimer: “My field of specialty is Healthcare IS.” This is true; my market knowledge is limited to HIS. However, I did note to him that healthcare administration is more of a girls’ club than is IT (which is ALWAYS referred to as the boys’ club).
My response? Women earn the majority of undergraduate and graduate degrees, AND they are vastly over-represented within healthcare administration, which means more competition for the higher level roles (manager and director level for the case in point). My thought was (and I am interested in reader opinions) that he would have an easier time finding management opportunities in IT, since there are likely to be more men (fewer degrees) than women. I see him having better growth with fewer women around. The other factor is that he has spent the last 10 years in IT, not in administration.
Anyone disturbed by my analysis may send complaints to Lawrence.Summers@harvard.edu. Larry offered to field them for me. Let me also state for the record: my specialty is strongly focused on clinical IS. Women make up the majority of my placements. The rest are very likely to fall into other “protected” classes. I am curious if my perceptions match the reality (real or perceived) that you experience.
A final point that I did not share with this fellow: I’m asked all the time about “how the market looks.” Since that is the most frequent question I hear, I figured I would share. Now is not a bad time to look for something new. I’m not selling here; as far as I know, only Mr. H. and Inga know me by other than my pseudonym. Given the general perception of the economy, many people are reluctant to explore right now (being low man on the totem pole, can’t sell the house, etc). Less people exploring means less competition, especially if you work in a higher level role.
Thoughts on HCSC’s Proposed Acquisition of MEDecision
By Lazlo Hollyfeld
I’m not surprised that MEDecision got bought by HCSC, but the price they paid was pretty baffling. They were on the block since last year, when everybody in the C-suite except St. Clair was ousted/left. The way I figure it, HCSC folks wanted to have more a direct say in things, including development, and saw this as a way to compete with the other big plans who have already made these types of strategic moves (e.g, Aetna with Active Health Management).
But why the crazy price tag? If anything, HCSC could have driven a hard bargain and picked it up on the cheap, potentially. MEDecision does it as a way to clear off a ton of debt and keep development moving forward. Otherwise who knows? That’s just conjecture, though.
While they have a solution (Alineo) that is pretty good and better than some of their competitors (e.g, CareAdvance) their client base is primarily Blues plans. It is just too expensive, really, for any mid-market plan with less than 200-250k covered lives. Say that they are focusing on TPAs and government plans but TPAs don’t have money to spend on a solution this robust (and expensive). Same for government plans.
That means they really are just making money on customers that are migrating and upgrading to the new Alineo platform off a stable but limited install base. The only way to really upgrade their revenues there to win a whale (say at least 750k covered lives) but they’re facing a bunch of competition from existing vendors (Trizetto, McKesson Health Solutions, Landacorp) and a cost of small upstarts using newer technology (ZeOmega, others).
NextAlign is interesting and the Patient Clinical Summary actually does deliver some valuable data to providers (even if it’s administrative data). It makes particular sense in emergency rooms if select physicians can just get over their bias that all administrative data is garbage (yes, problematic, but is it really better than nothing or relying solely upon a patient’s recall when they have multiple chronic diseases? Problem is, it is just way too expensive for providers to seriously consider purchasing this even if subsidized by a local payer. Will providers take it for free? Sure, and they will use it some select cases, but they balk at paying for it and they have a bit of a point.
This is really not an issue just for MEDecison. Every payer is facing this same challenge of how and where it makes sense to touch/interact with providers. Every large payer is conducting pilots this year with select providers, but they are mum about the results, either because they have nothing yet or regard it as too important of a differentiator from competitors. My bet is a bit of both, but mainly the former reason.
One thing I would love to see is some actual decent survey stuff on what/how physicians view using administrative data for clinical reasons, including diagnosis and treatment. My bet is that older physicians and those with a heavy bias against insurers are also those most likely to never use anything the payer sends regardless of its actual utility or value.
I’m curious to see where this goes and what is actually under the hood of the latest version of MEDeWeaver (RHIO/HIE play). Is it similar to what Ingenix is doing for State of Wisconsin with their recently announced deal? I’m also interested to see where the whole NextAlign thing goes, too.
The PACS Designer’s Open Source Software Review – Endrov
By The PACS Designer
Endrov is both a library and an imaging program. The design has made strong emphasis on separating GUI code from data types, filters and other data processing plugins. The idea is that the program can be used for most daily use or prototyping, and for bigger batch processing or integration, the code is invoked as a library.
As a program, Endrov can do what you expect from normal image processing software. It is meant to be hackable; integrating new editing tools, windows and data types is meant to be simple. The main features that set it apart from other imaging software is that it can handle additional dimensions (XYZ, time, channel) which is needed for more serious microscopy. Filters can also be used without being directly applied, and can be composed into filter sequences. Data (for example, derived from analysis) is stored together with the images.
The native image format is OST(Open Spatio-Temporal) Imageset Specification, but most other formats are also supported.
Version 2.10.0 is out, with a big overhaul of 3D rendering. It supports multiple transparent objects better and has many internal improvements to simplify writing new plugins. Other than reacting faster to user input and making use of all your CPUs/cores it comes with the following:
(1) New voxel renderer, render modes and improvements to the old one
(2) Clipping planes
(3) Scale bar
(4) Partial OST3-support
(5) Reworked Matlab bindings
(6) New nuclei rendering options
This new version supports expanded multi-modality viewing.
Endrov is for the image analysis professional who wants an open source solution that can be customized to their liking when downloading image files for interpretation. The files can contain images and data so better analysis can be obtained from a single image view. Version updates have been frequent and come from the highly regarded Karolinska Institute, a medical university in Sweden.
TPD Usefulness Rating: 8.