Practitioners Face Risks in Not Using Their NPI
by Legal and Regulatory Affairs Staff
February 14, 2008 -- If you are not using your National Provider Identifier number (NPI) by May 23, 2008, you risk having your claims rejected by all health insurers with which you do business. And if you are a "covered entity" under the Health Insurance Portability and Accountability Act (HIPAA), you may be subject to enforcement action by the U.S. Centers for Medicare and Medicaid (CMS).
The NPI is a unique 10-digit number assigned to every health care provider or entity that applies for it. This number replaces other provider identification numbers, such as Medicare's Unique Physician Identifier Number (UPIN) and other legacy numbers, historically assigned to health care professionals by government and private insurers for use in billing.
All health care practitioners who are considered "covered entities" under HIPAA are required to obtain an NPI. Practitioners who electronically transmit health information in connection with specified transactions such as submitting health care claims and determining eligibility for a health plan are among the "covered entities."
The NPI usage requirement was initially scheduled to go into effect on May 23, 2007. CMS decided in April of last year that it would not enforce this deadline due to concerns that many insurers and practitioners were not ready to comply. However, CMS plans to enforce the rule beginning this coming May 23, and has statutory authority to issue penalties of $100 to $25,000 per violation.
More immediate than the possibility of federal penalties, however, is the risk of interruptions in your cash flow. Beginning May 23, 2008, federal law directs payers not to process claims that lack an NPI.
If you electronically submit a claim without an NPI, your claim likely will be rejected. A practitioner then will have to go through a potentially lengthy process of notifying the payer that you have an NPI and resubmit the claims with your NPI number.
In addition, payers may reject claims that contain a legacy number, even if the claim also contains an National Provider Identifier. CMS has already announced on its Web site that it will reject claims containing a legacy number. As of May 23, therefore, claims should include your NPI and only your NPI. Although the law requires only covered entities to obtain NPIs, insurers are free to mandate NPIs from all providers, even those that are not covered entities and who submit paper claims. Medicare, for example, is requiring NPIs from all providers and on all paper claims, as well as on electronic claims.
If you have not yet obtained your NPI, you may apply for one online at https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart.
If you have questions about obtaining and using your NPI, please feel free to contact Maureen Testoni, J.D., in the Practice Directorate at 202-336-5886 or by email at praclegal@apa.org.
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