Health Information Compliance Alert

What constitutes a good faith effort?

Guess who gets to decide if you're complying with the new National Provider Identifier requirements--the Centers for Medicare & Medicaid Services.

With less than two months left before crunch time, CMS decided to give you until May 23, 2008 to become NPI-only with all your transactions. That includes using referring physicians' NPIs instead of UPINs on all claims.

If you're not quite ready by May 23, 2007, you can implement a "contingency plan" to maintain your cash flow, CMS says in a release.

Why the change: CMS tries to make it sound as if providers weren't ready for the original deadline. But CMS was also behind on its obligations, notes the Medical Group Management Association. CMS  failed to issue a policy that would "facilitate the communication of NPIs," says MGMA's William Jessee in a release.

Without any CMS policy, providers didn't know how to obtain the NPIs of doctors who referred patients to them. The MGMA has posed a sample letter to request a referring doctor's NPI on its site at www.mgma.com, but CMS has been promising a "Data Dissemination Notice" on NPI-sharing for years now.

The lack of this CMS policy has "hindered industry efforts to meet the original compliance date," MGMA says.

Sustained Actions, Demonstrable Progress Key To Compliance

But getting into compliance with the new NPI postponement may be trickier than it first appears. CMS' wording about the matter is vague and confusing, says attorney Robert Markette Jr. with Gilliland Markette & Milligan in Indianapolis.

To avoid penalties, a provider must show a good faith effort to comply with the NPI rules in the first place. CMS will determine "on a case-by-case basis, whether reasonable cause for the noncompliance exists and, if so, the extent to which the time for curing the noncompliance should be extended," the agency says in its contingency plan guidance.

Tip: That means providers should have their own NPI numbers and be ready to go by the original deadline. "Make the effort to be in full compliance by May 23, 2007," urges consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN.

Hitch: Providers can't be fully prepared for NPIs until CMS explains how they can obtain the NPIs of referring physicians, warns Martin Jensen, chief operating officer and chief analyst with Health IT Transition Group in Tulsa, OK.

Try this: To show that you've made a good faith effort to obtain your referring physicians' NPIs, you might document something like this, Gaboury suggests: "Dr. Jones, Dr. Smith and Dr. Thompson have not obtained and shared their NPI numbers. A letter has been sent and a phone call made to the physicians to obtain this information and formal information regarding NPI shared."

Important: "In determining whether a good faith effort has been made, CMS will place a strong emphasis on sustained actions and demonstrable progress," the agency says in its guidance.

Thus, a provider might also document something like this, Gaboury offers: "Followup will continue with these physicians every two weeks until we have received (NPI) information." Then the practice must actually document the followup effort every two weeks until compliance.

The key to showing the good faith effort will be having a solid plan with certain steps that show your progress, Markette counsels.

Resource: To review the CMS' policy NPI compliance or review the policies governing "good faith" extensions, visit http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPI_Contingency.pdf.