Medicare Compliance & Reimbursement

Avoid payment hold-ups with 'good faith effort' on NPIs.

If some of the payors you deal with or some of the providers who refer to you aren't up and running with national provider identifiers (NPIs) by May 23, you could be stuck in a no-win situation.

You may be forced to include a unique provider identifier number (UPIN) or other legacy number for some of your referral sources, for example. "It means having to cater to one provider, adjusting numbers," says Linda Huckaby with Carolina Medical Rehab in Greenville, SC. With electronic claims, there's no telling how much adjustment you'll need to do for them to appear "clean," she adds.

If some of your referral sources don't have NPIs by this May, you can complain to the Center for Medicare & Medicaid Services (CMS), notes Michael Apfel, chief privacy officer with Truman Medical Centers in Kansas City, MO. But there's no way of knowing how long CMS will take to respond to those complaints.

"Some providers made the business decision not to accept a referral if the referring provider's NPI is not on file with them," Apfel adds. "Others have been engaged in aggressive letter-writing campaigns, with mixed but generally positive results." You have to make "a business decision that makes the most sense" for your practice, he says.

But if you're stuck accepting referrals from doctors who haven't given you their NPIs, you may have no choice but to take advantage of the one-year grace period yourself, say experts.

Getting into compliance with the NPI postponement may be trickier than it first appears, says attorney Robert Markette 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 your doctors should have their own NPI numbers and be ready to go by the original deadline of May 23, urges consultant Melinda Gaboury with Healthcare Provider Solutions in Nashville, TN.

Be Persistent

To show that you've made a good faith effort to obtain your referring physicians' NPIs, you could 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 share formal information regarding NPI."

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, you could also include this language in your documentation, Gaboury offers: "Follow-up will continue with these physicians every two weeks until we have received (NPI) information." Then the agency must actually document the follow-up effort every two weeks until compliance.

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

Be reasonable: Remember that "the contingency plans, like everything else in HIPAA, are scalable," advises attorney Ross Lanzafame with Harter Secrest & Emery in Rochester, NY. That means what's appropriate for a company with 10 employees may not be what's appropriate for one with 100, Lanzafame says.

Providers "can consider cost in determining what is appropriate," Lanzafame allows. "However, cost cannot be the sole reason for deciding that something is inappropriate."

The second part of NPI compliance is the contingency plan. CMS says it won't impose penalties on providers that deploy contingency plans "to ensure the smooth flow of payments." But you have to wait until CMS issues its own contingency plan before you know for sure how you can bill Medicare without the referring physicians' NPIs after the May 23 deadline.

Listen up: CMS says it will issue its plan soon, and the agency has scheduled an April 18 conference call about NPIs.

Brace yourself for the possibility that your software may reject claims that don't carry your or your referring physicians' NPIs, Gaboury warns.