Listing of recent grants for healthcare technology...

Tired of the ambiguities and outdated constraints of the electronic claim, remittance advice, eligibility and other X12 transactions? Help is on the way. Or at least it's coming into view. The enabling regulation to adopt a new version of those standards has cleared the Department of Health and Human Services and has been passed on to Office of Management and Budget for final review. OMB has 30 days to approve it (with or without revisions negotiated with HHS) or reject it. I was fortunate to have the opportunity to participate in some of the X12 workgroups that built the new standards, and am certain that the new standards will improve efficiency and reduce the number of customizations and workarounds. We won't be able to say goodbye to those nasty Companion Guides, but at least they will be thinner. Besides reducing ambiguity in hundreds of passages -- saying when NOT to send data as well as when to send it, for example -- the updates incorporate a number of issues currently vexing implementers...

Are you a provider having trouble meeting the Provider Taxonomy requirements of one -- or several -- of your payers? Are you a payer learning the hard way that the Taxonomies you ask for and the ones you actually get are many miles apart? If it's any consolation, you're not alone. But now, there's hope....

We were a bit surprised to hear so little about the impact of the new "NPPES must match IRS" policy we reported on two weeks ago and subsequently dug into in relation to the secret crosswalk logic the next day. Letters were supposed to go out right away. Providers should be getting them within a couple days, and then we would know the facts, which rarely get full exposition in formal CMS announcements. We saw the search stats go up as people Googled IRS+NPI, IRS+NPI+crosswalk, etc., so we figured word must be getting out. Wait For It... Then comes this note posted to a public listserv: "We have had a pharmacy report that they received one - they said it took 9 days to reach them and they were concerned that they only had one day to react before being cut off!" Totally Tubular, Dude! Hello? If that's true, we have a big wave about to break. A potential tsunami that could make May 23 look like a...well, a pretty good breaker, with a tube and a long reach, but still, just a regular wave.....

If you came here looking for free information about your NPI problems, you will find lots of it. Click here for more than 125 articles we've posted on the subject in the last three years. We'd like to help you more directly, if we can. For the past few weeks, we worked on a concept to develop a "Crosswalk Coach" service that we could streamline and offer at a bargain-basement price to help the small clinics and others who were looking at years and months of Medicare denials. We even drew up a clever superhero character to represent the guy who would get you safely across the street. No Cookie Cutter We had to abandon the concept. There are no cookie cutter approaches to this problem. We've learned that some providers are simply in a catch-22 situation, where solving one payer's problem only creates problems for others. We can help solve some of those problems, but not necessarily all of them. You may be experiencing an issue that can be fixed quickly, and we hope you do. But we simply can't guarantee anyone safe passage, as much as we'd like to. So, in our forthright sort of way, we will offer instead...

Yesterday we posted the first public glimpse of the logic that Medicare is using to map incoming claims against providers NPPES (NPI) records to find matching Medicare PECOS (enrollment) records. If you missed it, you can download the spreadsheet here: MatchingRecipesWithCounts05_27_08.xls We also published an analysis of what CMS's new warning about NPPES/IRS mismatches might mean to providers who thought they were safe (see CMS Adds IRS Domino to Tumbling NPI Data). If you get a letter from CMS, will the changes they force you to make create a problem that requires an 855 enrollment (PECOS) update? If so, it could result in months of suspended claims. The crosswalk file gives us a clue, especially since it gives daily counts of which rules are firing....

Highlights of government and private grants for healthcare technologies for June, 2008

This is the post where we publish the Medicare NPI Crosswalk. SHHH! Don't tell....

Back in the day, I used to believe that everyone in this industry was operating with the best of intentions. Increasingly, though, I am starting to side with the most cynical of my provider colleagues who think that Medicare just doesn't want to pay claims. Even as the Department's non-compliant, non-transparent NPI edits are quietly snarling claims all over the US, they have added a new flaming hoop to the race course: Your NPPES (NPI) data must not only match your OSCAR (Medicare enrollment) record, it must also match what the IRS has listed -- somewhere -- as your legal business name.(LBN) Here's what the notice says, and here are the staggering implications...

Thanks to Jose Luis Gonzalez at ANCO for posting a link to this document by Medicare carrier NHIC, which lists their top 3 NPI errors and how to solve them. Interestingly, the solutions generally seem to indicate a "less is more" approach -- take stuff out to get the claim through. The one-pager is remarkalby succinct and actionable. A good example of the kind of transparency we've been advocating CMS adopt house-wide. Though NHIC's tidy little message falls far short of a full explanation of how Medicare is crosswalking claims data to PECOS data, it should provide a good guide for providers encountering the edits they list (M402, M417 and M419; M381 and M379, respectively)

Medicare shoots out one carefully-worded story and it starts bouncing around the echosphere: Our Experts Agree, Everything Is Fine. This version comes from the HFMA website: "most of the Medicare contractors [are] reporting that over 90 percent of claims are NPI-compliant." We immediately posted our response, which said, basically, that "NPI-compliant" was a meaningless term, since it didn't address whether the claims would be properly crosswalked or paid, and that even 10% was an awful lot of rejections, when it comes to Medicare. But in absence of any real news (like real adjudication rates, real payment levels, etc.) from Medicare, the story keeps bouncing around the HIT world. Okay, here's some news, folks. Taken directly from CMS's own statistics, using a "per business day" calculation based on 250 working (and billing) days per year against unadjusted 2006 numbers. 10% of daily Medicare claims means that 386,853 claims are bouncing every day. 10% of daily Medicare payments means that providers are going unpaid to the tune of $149 million every day. Today is the 10th business day since May 23. Do the math: 4 million claims, $1.5 billion dollars. Here's the other news: Medicare's numbers are grossly underestimating the problem. Why?...

Yesterday, an alert reader caught the notice that CMS had recinded MM5980, the Medlearn Matters article that told Medicare providers they need to violate HIPAA by plugging in their own NPI when a secondary provider (Referring, Ordering, Attending, etc.) did not have an NPI. (See Is Medicare Backing Off Noncompliant NPI Strategy?) Now, an even more alert (or perhaps well-connected) reader, let's give her the code name Mrs. Plame-Wilson, says somebody inside CMS told her it's just a content-related error that prompted the memo to be withdrawn. The rules haven't changed since Medicare changed them. Don't worry, you can still add the spaghetti code to do that noncompliant kluge that will get your claim past our edits. (I'm paraphrasing here, to protect my source's Covert Ops status.) In other words, "We're still going to violate HIPAA." Which Gorilla Do You Listen To? Behind this happy news come even more stories about small providers getting bad advice. One says that her Medicare contact told her to enumerate her small clinic, even though it is a sole proprietorship and the doctor/owner already had his own NPI. Another said that Medicare of Florida/First Coast is telling her that she needs to put their service facility information -- for 200 sites! -- into the Billing/Pay-To loop instead of where the 837 rules say to put it (clue: loop 2310D is referred to in the 837P as "SERVICE FACILITY LOCATION"). And they also say she needs to submit the claims in 200 different batches....

Alert Reader "ImNPIready" (I'm pretty sure that's a pseudonym) noticed that Medicare's instructions to falsify NPIs to get past their own edits seem to have been withdrawn. In a message distributed last night to Medicare Fee-For-Service lists comes the terse announcement: Article MM5890 has been rescinded. While we do not normally remove articles from publication, MM5890 was removed per CMS instructions. We've railed about this here -- like a lot of the issues we cover, it's got some technical nuance to it, but the basic instruction was "If you can't find an NPI for a secondary provider, put your own NPI in as the identifier for Referring, Ordering, Attending, etc." The problem with the instruction is that it overturns the fundamental principle of standards (that a data element refers to what it is supposed to refer to, not some other receiver-specific value) and the law itself (the Transactions and Code Sets Final Rule says no one can redefine or repurpose a data element)....

Medicare may love the numbers it is getting, but billing software vendor Misys wants to help their provider customers before they overwhelm their tech support department. So late last week, they sent out a fax broadcast. Download rejectionsfaxanon.jpg Due to the high number of rejections, Misys is receiving a record number of phone calls to assist you with intrepreting and resolving these rejections. Here are some suggestions for how to troubleshoot rejection problems before calling Misys. Given our own analysis, which suggests that, even after the Medicare SNAFU is largely behind us, providers will be confronted with a mounting series of unattainable, conflicting payer instructions, we particularly appreciated the validation in the vendor's first recommendation: Check out the new section link on our NPI website for Payer Specific NPI Issues. Wait, wasn't the purpose of NPI to let providers out of the Flaming Hoop Identity Relay?

Despite widespread reports of significant claim disruptions, Medicare issued a note that says that "the favorable trend in NPI compliance is better than we expected with most of the Medicare contractors reporting that over 90 percent of claims are NPI-compliant, with some reporting 100 percent compliance." I never trust it when anyone uses that c-word. CMS has assiduously avoided defining "HIPAA-compliant" in the long history of Transactions and Code Sets implementation, so "NPI-compliant" should not be taken to mean what this soft-pedaling would lead one to believe. (It's also worth noting that 10% of Medicare claims is an awful lot of unpaid bills.) The real question is, "How many claims are getting through adjudication?" Even gettting Medicare to "accept" the claims is, as so many have learned, no guarantee, as notice of crosswalk failures sometimes appear in the form of ADR letters received weeks after the claim was "accepted." And yes, those claims could easily have been "NPI-compliant" -- in fact, lack of a legacy ID is one of the things that leaves Medicare's crosswalking process clueless as to how to pay. If All Else Fails, Contact Someone Who Cares In a pale acknowledgment of the problems that have already vexed some providers for months, the letter offers a glimmer of hope...

Breaking news from Joe Conn at Modern Healthcare: Medicare and Medicaid rejections are still huge after a week of effort, according to Miriam Paramore at Emdeon. I have to tell you how brave it is of them to state this publicly, since their customers are likely blaming them for the problem. Isn't it the clearinghouses's job to fix stuff like this? Regular readers will know that the smoking gun lies elsewhere. Just click on the NPI category on the right side of the page for about three years of clues. I would also like to point out that the 25% rejection rate is not an indication that every provider will see their Medicare check drop to 75 cents on the dollar. Instead, many will see no impact at all, why a few (that's a word I borrowed from CMS to describe NPI crosswalking problems) will get a big fat goose egg. It's almost seven and it's Friday night. Busy week. Gotta go, folks. Keep posting your own NPI stories on our Open Thread.

We posted earlier on the National Uniform Billing Committee's request for a 6-month extension to the NPI Contingency period. Their brothers and sisters in arms, the National Uniform Claims Committee, sent a similar letter, and a few days before the deadline, they seem to have gotten a response. This letter was distributed on a public listserve, so I don't believe it is confidential in any way: HHSresponsetoNUCCletter051908.pdf

We do not feel it appropriate to continue the use of contingency plans past May 23rd, as it is imperative that the industry continue its move towards compliance. There are likely to be some outlier technical and operational challenges, but we expect the industry will continue to resolve those together.

It's signed by Anthony Trenkle, Director of CMS's Office for E-Health Standards and Services. OESS is responsible for enforcing the HIPAA transactions regulations, including the NPI Final Rule. I ran into Tony at a conference last fall and he told me he reads the blog and said, "You know, you can call me if you have a concern." In fact, he encouraged me to call him when I got back to Tulsa.

I sent him a note saying that he was a busy man, and I was just a blogger, and it would probably be easier for him to reach me that for me to catch him between meetings. Guess he's been busy.

This is Going to Hurt You a Lot More Than it Hurts Me
I'll admit I had another reason for my reluctance to call. I've learned that CMS folks have a hard time saying anything that strays from a firm Company Line. Also that, even if they say something off-message in private, if I then publicize it, they tend to get taken to the woodshed, after which comes a public retraction or contradiction. Of course, as Chief of the HIPAA Police, Tony is more likely to be the guy waiting in the woodshed than the guy that gets hauled out there.

Still, my offer stands and my line is open. Tony? I think you have my number, if not, drop me a line. Otherwise, you can continue to read my advice here, or, if you want the full scoop, buy a copy of the NPI Contingency Status survey analysis, which explains how to get out of this mess we're in. (Readers, I should also point out that, via our "Buy-one, Send-one" offer, if you purchase a copy for yourself, we will send one to the government official or trading partner of your choice. Quite a deal. Why not send Tony a 100-page report to read over the weekend? Or maybe your friendly neighborhood Medicaid plan or Medicare FI?)

Back to the Letter from the Law
I'm thinking, "resolving things together" might ought to include asking your pals at Medicare to have sufficient staff available to answer the phone calls about those outlier technical and operational challenges, and getting the data entry of those handfuls of re-enrollments to happen in hours or days instead of weeks or months. But who am I to judge?

Oh, that's right. I'm a taxpayer. That makes me The Boss, right?

Handle it!

Earlier this week, we invited providers to tell their stories, good or bad. Most of the stories I've been getting have been coming in via email and phone calls. So many, I can't keep up. It's clear that we have a serious disruption going on. CMS's note to Medicaids (NPIDailyReportGuidance.pdf) said these elements would constitute a "Status Red":

• Claims Processing: Consistently high claims denial and suspense levels, significant claims denial/suspense backlog
• Provider Payments: Providers not being paid timely
• Media: Media interest and negative coverage
• Call Center: Significantly increased provider call volumes and backlogs
• Contingency: Added staffing, increased paper claims, interim provider payments

So, providers, my blog stats are shooting through the roof as this implementation hits the fan. That constitutes "Media Interest." I'm pretty sure our coverage of the situation would not be considered positive, so we've got "Negative coverage" in the bag, at least at the national level.  How about commenting on some of those other bullet points?

Unlike the daring civil servant I felt it necessary to protect, you might want to name the state plan, Medicare carrier or other private or government payer you are having trouble with. Facts are great, but opinions matter, too.  How do you feel about the way things are going?

I'll turn off comment moderation for the time being, so your comments will display immediately.

Just click on the Comments link below to read or post.

In today's Modern Healthcare Online, Joseph Conn puts some numbers up on the board from a verifiable source. Emdeon's Miriam Paramore goes on the record, saying that their Medicare claim rejections have jumped by a factor of four since last week, from a typical daily rate of 6% to 24% this week. (See Claims processors see rejections spike with NPI)

It's worth noting that even this big multiplier may understate the issue. The typical daily rejection rate will tend to include a lot of coding errors. In general, the submitter looks at them, fixes the problem, and resubmits.

Then the provider gets paid.

This extra 18% may include a lot of claims that aren't so easy to remedy under Medicare's new rules. Crosswalk errors that require the provider to submit an update to the 855 enrollment form, for instance, may take weeks or even months to be reflected in Medicare's registration database. Until then, the claim payments might just go on permanent vacation, as so many providers have reported.

Likewise, the 6-fold increase in Medicaid rejects (from an average of 4% previously to 26% on May 23) will not only include a number of hard cases, but may also include the regional impact, since each state will have different edits and different internal system challenges. The 26% average will include a lot of states that are doing better, but some that are doing far worse at getting claims through.

And I probably ought not mention that clearinghouse throughput is not quite the same as adjudication and payment. Should I?

Nor should I mention that a lot of providers bill Medicare directly, without going through a clearinghouse.

That would be depressing.

Just when you thought Medicare was being a bit too hard-nosed about enforcing its idiosyncratic interpretation of the NPI Final Rule on an unprepared industry, along comes the news that they are willing to be flexible -- at least when it comes to filing their own claims. Check out this missive that just went to the secondary payers that receive Medicare electronic crossover claims:

To All COBA Trading Partners:

COBVA--Clarification Regarding Provider Values Received on Crossover Claims Following and Inclusive of May 23, 2008

The Centers for Medicare & Medicaid Services (CMS) is alerting all Coordination of Benefits Agreement (COBA) crossover trading partners that, for a period of 30 days beyond May 23, 2008, inclusive, they may not see NPI values exclusively in the NM109 "primary" and "secondary" provider segments throughout their 837 institutional and professional crossover claims. Instead, COBA trading partners could, in a limited number of instances, see non-NPI values--specifically, either the provider's employer identification number (EIN) or social security number(SSN)--within the "primary" provider NM109 segments on claims within the 2010AA, 2010AB, or 2310B loops. COBA trading partners will detect greater instances of non-NPI values (i.e., EIN or SSN) within the NM109 segment of the various "secondary" provider loops (i.e., Attending, Operating, Referring, Ordering, Service Facility, Purchasing, Supervising Provider, etc.) for 30 days following and inclusive of May 23, 2008. The basis for this reality is that Medicare accepted claims for adjudication up through May 22, 2008, that contained provider EIN or SSN values within the "primary" and "secondary" provider loops. Though rare, COBA trading partners may also encounter situations within the "secondary" provider loops that contain, for example, reporting of the NM101-NM103 segments only within the 2310A (Referring Provider) loop.

COBA trading partners should expect to see the majority of the aforementioned scenarios diminish around June 5, 2008, with the incidence of EIN or SSN appearing in the NM109 segments ceasing around June 22, 2008, following Medicare's complete clearing of its payment floor. Prior to June 23, 2008, as the Medicare contractors' payment floor fully clears, the Coordination of Benefits Contractor (COBC) will continue to send claims to COBA trading partners that may not contain NPI values in all NM109 segments. Please note that the COBC will not accept disputes from COBA trading partners for claims that it transmits to them prior to June 23, 2008, if the basis for dispute is that they are missing required NPI values in the NM109 segments.

Effective June 23, 2008, the COBC will activate editing of incoming Medicare claims to ensure that they contain NPI values in the "primary" and "secondary" NM109 segments. Upon activation of this editing, the COBC will begin to reject claims back to our Medicare contractors. They, in turn, will notify the affected providers specifically that these claims, which failed the COBC's translation process, could not be crossed over due to the lack of an expected NPI.

Should you have questions regarding this announcement, contact your designated CMS or COBC EDI representative. [Emphasis theirs]

Decoding the Spaghetti
For readers who don't speak Medicare Bureaucratese or the Nth Degree of the X12 dialect, let me offer a bit of translation:

• Many Medicare beneficiaries have additional coverage under a state Medicaid plan, numerous commercial plans, and other government plans. In many such cases, Medicare sends these plans a "crossover" claim, rather than just telling the provider what they paid and letting the provider send a separate bill to the other payer.
• These crossovers are submitted via the ASC X12 837 standard, using certain rules and formats designated specifically for that purpose. This process is called a payer-to-payer "Coordination of Benefits" or COB transaction.  For the past few years, all Medicare COBs have been processed by a single contractor, GHI, who is the source of this email (referred to here as "COBC").
• The instructions above indicate that GHI will continue sending claims containing non-NPI primary identifiers, and sometimes NO primary identifiers, when the original claim came to them before the May 23 drop-dead date.  (The "payment floor" refers to the arbitrary time period that Medicare decided to add after they adjudicated the claim, but before they release the crossover -- a full month of float that costs providers millions of dollars a year, but that's another story).
• It's perhaps worth mentioning that these crossover 837's are HIPAA standard transactions, therefore both the sender and receiver is obligated by law to conform to the Transactions and Code Sets Final Rule, the NPI Final Rule, and the ASC X12 837 Standard.

But in this case, Medicare/CMS has given itself permission to violate its own noncompliant version of that NPI Final Rule, under which it insists that NPIs and NPIs only must be sent on claims as of last Friday and forever more. This is the rule it is using to reject provider claims that don't conform to its own noncompliant kluge -- that providers send their own NPIs when it can't find one for a Referring Provider or other so-called Secondary Provider loop. Interestingly, the rules Medicare is using for its own COBs look a whole lot like what X12 said billers should be able to do -- now, and forever -- when they don't have an NPI for a secondary provider.

Because the Gorilla Said So
I liked this bit, where they threatened their trading partners not to challenge them: "Please note that the COBC will not accept disputes from COBA trading partners for claims that it transmits to them prior to June 23, 2008, if the basis for dispute is that they are missing required NPI values in the NM109 segments."

Excuse me? Not accept disputes? Sounds like the gorilla is saying "Talk to all four of the hands," when it comes to their own NPI violations to me....

Maybe providers could try that strategy: "Oh, you're covered by Medicare? Sorry, we don't accept patients from rule violators."

For People Who Can't Deal With Drugs
So is any of this good news for providers? A bit. At least last month's crossovers will be a bit more likely to go through.

Perhaps more encouraging is the tiny glimmer reflected by a single word that we haven't seen referenced in any recent NPI missives from CMS:

"Reality."