Home Health & Hospice Week

Problem: When the National Provider Identifier requirement takes effect May 23, home health agencies must bill using the new NPIs instead of their old Medicare or other payor numbers.

The catch: HHAs also must put on the claims physicians' new NPIs rather than their old UPINs. Most HHAs seem ready with their own NPIs, notes Gene Tischer with trade group Associated Home Health Industries of Florida. "But many fear their referring docs won't be ready," Tischer tells Eli.

Solution: Providers will have a 12-month extension on NPIs, the Centers for Medicare & Medicaid Services just announced. "CMS made the decision... after it became apparent that many covered entities would not be able to fully comply with the NPI standard by May 23, 2007," the agency says in a release.

The Department of Health & Human Services "recognizes that ... non-compliance by one covered entity may put [a] second covered entity in a difficult position," CMS adds.

The reprieve isn't just a straightforward extension, however. Providers must show that they are making a good faith effort to get into compliance with the NPI mandate, which is required by HIPAA. They also must have a contingency plan in place for the period after the original May 23 implementation date, if they aren't yet using their NPIs.

CMS gives a few pointers on how to show good faith efforts and craft contingency plans in a guidance document, notes attorney Jim Pyles with Powers Pyles Sutter & Verville in Washington, DC. Think of it like this, Pyles suggests: HHS will approve your contingency plan if you have made reasonable and diligent efforts to become compliant by the original deadline.

CMS will enforce NPI compliance based on complaints, the agency explains. If it receives a compliant, it will notify the provider. Then the provider can 1) show its compliance, 2) document its good faith efforts to comply or 3) submit a correction plan.

But CMS ultimately will decide whether you are complying with the good faith requirements, warns attorney Robert Markette Jr. with Gilliland, Markette & Milligan in Indianapolis. (For more information on meeting this requirement, see next week's issue of Eli's Home Care Week).

Under the extension, it appears agencies will be able to bill Medicare for home health services using the physician's UPIN, Tischer notes.

Reimbursement consultant Melinda Gaboury knows of nothing that currently would hold up a home health claim without a physician NPI. "Without the NPI, they would continue to use the UPIN," says Gaboury, with Healthcare Provider Solutions in Nashville, TN.

Providers should spell out under their contingency plan that they will use legacy identifiers such as UPINs, Pyles says.

But UPIN approval won't be final until CMS issues its own NPI contingency plan, which the agency says it will do "shortly." The same goes for other payors you submit claims to.

Pick up the phone: Agencies will just have to wait on payor billing instructions, Markette says. Or you can contact your payors and ask what to do once the May 23 deadline hits if you don't have physician NPIs, he suggests.

Trap: Some HHAs may get into trouble because CMS will likely allow billing with a UPIN instead of an NPI, but their own software won't, Gaboury warns.

Gaboury encourages providers to aim for compliance with the original May 23 date rather than risk billing and compliance complications.

Another wrinkle: The delay in implementing the new CMS 1500 form, which uses the new NPI, may have given CMS more reason to offer an NPI extension, Pyles notes.