| Motivation - Poor Provider's Data Quality | | | | and reporting. It |
| The provider's demographic data is dynamic by | | | | - Simplifies communication and administration |
| nature. Providers move their offices, add facilities, | | | | - Facilitates efficient electronic transmission of health |
| change their phone numbers, are sanctioned and stop | | | | information |
| practicing. Poor healthcare provider's data quality | | | | - Streamlines detection of billing fraud and abuse |
| affects virtually every aspect of healthcare payer's | | | | - Improves debt collection efforts |
| enterprise, diluting profits and member goodwill. Their | | | | - Reduces cost to re-issue checks |
| applications, interfaces, databases, files and reports | | | | - Improves accuracy of provider directories and |
| currently use legacy provider identifiers. Provider data | | | | reduces support cost |
| often exists in not one but many disparate | | | | - Reduces cost of claim adjudication - the cost of |
| databases throughout a healthcare payer's IT | | | | auto-adjudicated claim is $.40, 10-fold less than a |
| enterprise, including multiple variations of the same | | | | manually adjudicated claim. |
| provider record. Provider's variations and discrepancies | | | | Means - NPI |
| generate as much as 12 percent of physicians checks | | | | - A unique 10-digit identification number |
| returned, raise numbers of support calls, increase | | | | - Assigned for life to a provider and de-activated only |
| manual claim adjudication, and impede identification of | | | | upon death, retirement, or identity theft |
| billing fraud and abuse. For instance, the cost of single | | | | - Replaces multiple legacy provider identification |
| check re-issue alone can reach $20 for opening | | | | numbers, including Medicare UPINs, commercial payer |
| handling, researching the correct provider, reissuing | | | | Ids, and state Medicaid IDs |
| and mailing the check. | | | | - Independent of key provider information changes, |
| Opportunity - HIPAA | | | | such as practice location or specialty |
| The 1996 Health Insurance Portability and | | | | Payer Challenges |
| Accountability Act (HIPAA) established national | | | | - Clean - Create good provider's records by |
| privacy and security standards for electronic health | | | | reconciling, standardizing, augmenting and integrating |
| care transactions, including a national identifier for | | | | legacy provider data. |
| providers, health plans and employers. Accordingly, by | | | | - Crosswalk - Build a crosswalk between NPI and |
| May 23, 2007, health care providers and all health | | | | legacy provider identifiers. Since many providers have |
| plans and clearinghouses must change both their | | | | multiple locations and affiliations, the crosswalk of |
| processes and information systems to implement | | | | NPIs to legacy provider identifiers used in different |
| HIPAA's National Provider Identifier (NPI) regulations. | | | | provider files might be a complex one-to-many |
| Successful transition to NPI is critical to every aspect | | | | mapping. |
| of operations and impacts eligibility and authorization | | | | - Maintain - Actively manage and clean provider data |
| processing, provider enrollment, contracts and | | | | records as they change in the future. |
| directories, claims adjudication and payment, referrals, | | | | |