(6/30/98) - Letters of Comment to HCFA regarding NPI NPRM
June 30, 1998
Health Care Financing Administration
U.S. Department of Health and Human Services
Attention: HCFA-0045-P
P.O. Box 26585
Baltimore, MD 21207-0519
RE: HCFA-0045-P
Dear Sirs:
The following represent the comments of the Workgroup on Electronic Data Interchange (WEDI) on the proposed rule regarding the adoption of the National Standard Health Care Identifier which is mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This proposed rule is referred to in the Federal Register as HCFA-0045-P.
Following its publication in the Federal register, the proposed rule was posted to the WEDI web site, along with a document generated by WEDI s ID Policy Advisory Group (PAG) which specifically highlighted the issues which the PAG felt it should carefully examine and comment upon. Then, WEDI hosted a two day session in Chicago on June 8 and 9, 1998, during which the ID PAG and other industry representatives reviewed both the rule in general and the specific areas within the rule on which comments were directly solicited. The session was open to both WEDI members and non-members, and it was well attended by representatives of the payer, provider and vendor communities.
The results of that session were a series of recommended comments to the proposed rule that were presented to WEDI s Board of Directors. On June 23, 1998 the Board met to review each such recommendation. The following comments are the product of the Board s deliberations and therefore, represent the organization s official positions on these issues. We believe that our comments represent the views of the broadest coalition in the health care industry, and we hope that they can contribute significantly to the timely preparation of the final rule on Standards for Electronic Transactions.
For ease of reference, each comment is identified as to the page number in the Federal Register and the issue to which it pertains.
Page 25323 (General)
The proposed rule notes that Section 1177 of the Act establishes significant penalties
for misuse of unique health identifiers. WEDI recommends that DHHS specifically address the fraudulent application for or of the National provider Identifier (NPI) in its promulgation of enforcement regulations.
Page 25323/1 (Background)
WEDI recommends that financial institutions and credit card processors not be exempt from the privacy and confidentiality requirements of HIPAA as noted on page 25323, column one(1).
Page 25324 (Provisions)
The proposed rule notes that a health plan may not delay the transaction & on the ground that the transaction is a standard transaction. WEDI believes that clarification of the term delay is appropriate and recommends that any such clarification or definition be expressed in terms of a comparison with the health plan s processing of similar transactions which do not contain the standard health care identifiers.
Page 25324 (Provisions)
The proposed rule indicates that clearinghouses could accept nonstandard transactions for the sole purpose of translating them into standard transactions & WEDI recommends that the word sole be deleted from this sentence, since a clearinghouse may have other legitimate purposes for receiving nonstandard transactions from its trading partners.
Page 25324/3 (Provisions)
WEDI recommends a modification in the NPRM s handling of corporate boundaries. Specifically, only transactions between owned entities should be excluded from HIPAA compliance, while transactions between contractually-related companies should not be excluded. This definition change would oppose the exclusion of the Medicare relationship with its carriers and intermediaries. WEDI further recommends that for purposes of these rules, federal agencies be considered corporations.
Page 25325 (Provisions)
The proposed rule would limit the definition of a health care provider to an entity that furnishes or bills and is paid for health care services.
WEDI recommends that this definition be tightened to specifically state that billing services do not get NPIs. WEDI acknowledges that billing services, clearinghouses and other electronic transaction processors will need some standard identifier to facilitate the routing of transactions, but those should be other than the NPI.
Page 25325 (Provisions)
WEDI proposes that the health care providers listed on page 25325, column 1 be expanded to include those who provide ancillary health care services such as transportation, home health, meals on wheels , etc.
Page 25325 (Provisions)
The proposed rule notes that identifiers may not be immediately assigned to all health care providers that do not participate in electronic transactions. WEDI recommends that NPIs be assigned as quickly as feasible to all requesting providers, regardless of electronic submission capability. This will more quickly reduce the cost to the industry of maintaining multiple identification systems. Also, it will enable certain
electronic transactions to be submitted in standard form even when they refer to a provider who does not utilize electronic transactions. For example, a physician may not submit claims electronically, but a pharmacy must utilize that physician s NPI when transmitting electronic pharmacy transactions.
Page 25325 (Provisions)
The proposed rule identifies two alternatives for categorizing health care providers. In the first alternative, providers would be identified as individuals, organizations, or groups. In the second alternative, providers would be categorized as individuals or organizations, which would include groups. WEDI recommends that the second alternative be adopted and that the definition of organization be revised to incorporate both the current concepts of organization and group .
Page 25325 (Provisions)
The proposed rule would modify the definition of health claim clearinghouse in the statute by further explaining that such an entity is one that currently receives health care transactions& WEDI recommends that the word currently be stricken from this definition. There seems no reason to exclude organizations which do not currently perform such functions but which may perform them in the future from coverage under HIPAA.
Also, in the same discussion of clearinghouse definitions, WEDI would modify the proposed rule as here underlined: & we would consider billing services, repricing companies, community health information systems, value-added networks, and switches, when performing these same functions, to be clearinghouses.
Page 25328 (Provisions)
WEDI reaffirms its previous recommendation that assignment of and utilization of the NPI not be required earlier than one year after publication of the final rule, except by willing trading partners.
Specifically, the proposed rule notes a recommendation made at the WEDI Healthcare Leadership Summit held on August 15, 1997. WEDI affirms that earlier recommendation that & health care providers not be required by health plans (words added here for clarification) to use any of the standards during the first year after the adoption of the standards. However, willing trading partners could implement any or all of the standards by mutual agreement at any time during the 2-year implementation phase (a 3-year implementation phase for small health plans). In addition, it was recommended that a health plan give its health care providers at least 6 months notice before requiring them to use a given standard.
WEDI further notes that a variety of issues remain to be addressed regarding the process of establishing, assigning and maintaining the new national provider identifier. WEDI believes that various segments of the industry will view those issues from different perspectives and with different objectives. Finding solutions and consensus in this atmosphere will be difficult, but failing to do so will create unacceptable costs and delays. WEDI has previously been able to forge agreements within the industry on a variety of EDI-related issues, and we believe that we are uniquely qualified to do so with respect to such NPI issues as enumeration, funding, implementation, etc. Therefore, because we represent the broadest coalition of health care industry organizations and because we remain wholly committed to the sole objective of increasing the volume and value of electronic transactions within that industry, we offer our services to DHHS as the Department attempts to establish the NPI infrastructure. Our services could include the convening of industry summits, the establishment of policy advisory groups, or whatever DHHS and our members felt might be in the industry s best interests.
Page 25328 (NPI Standard)
WEDI endorses the proposed rule s requirement that the NPI include a check digit to assist in identifying erroneous or invalid NPIs. However, WEDI notes that the proposed rule describes the handling of the check digit for alpha characters as an ISO standard when, in fact, this would be a HCFA extension of the ISO algorithm.
Pages 25328 and following (NPI Standard)
WEDI notes that the proposed rule describes the NPI as an 8-position alphanumeric identifier.
Alpha characters create significant problems in terms of data entry and are essentially incompatible with telephone keypad type devices and with the new generation of alternative computing devices (palm-sized computers.) They increase processing time and, we believe, the likelihood of error. In addition, they create greater complexity and cost for those who must modify existing systems within the health care industry at the same time that they are attempting to cope with the issues presented by the year 2000. Finally, an all numeric identifier would be more compatible with the ISO standards for health. Also, numerics tend to be more compatible with international, non-English alphabet standards.
Therefore, WEDI recommends that the proposed format NOT be adopted. Instead, WEDI recommends the adoption of an NPI which consists of 10 numeric characters with the 10th character being a check digit. Since WEDI agrees with DHHS that location codes should not be part of the NPI, the full identifier will be available for provider enumeration. This will permit the enumeration of one billion health care providers.
WEDI also would like to note that the transaction standards being proposed by the Department in a separate notice of proposed rule making (HCFA-0149-P) contain the capability of handling numeric identifiers longer than the one we propose, thus permitting expansion of the identifier during the next century.
Should WEDI s recommendation be rejected and the final rule stipulate that the NPI will be an 8-position alphanumeric, we recommend strongly that the NPI exclude the letters I, L,O,Q,S and Z. We further recommend that alpha characters be issued and used in the telephone keypad sequence: A,D,G,J,M,P,T and W.
Pages 25329 and following (NPI Standard)
WEDI affirms its previously noted position that intelligence not be embedded in the NPI.
Page 25331 (Requirements; Implementation)
As noted above, WEDI believes that the use of the NPI not be required until at least one year after the publication of the final rule, except by willing trading partners, Previously, WEDI also recommended that NPIs not be issued before 9 months following publication of the final rule. However, with better knowledge of and understanding of the NPI/NPS process, WEDI is withdrawing that recommendation.
Also, as noted above, WEDI offers its assistance to the Department in resolving any issues that might delay the timely definition and issuance of NPIs to qualified health care providers. Specifically, WEDI recommends that the decision on staggered vs. turn-key implementation be addressed by WEDI facilitated processes.
Page 25331 (Implementation)
Current identifiers, such as UPIN, may cease to be issued once the enumerator(s) begin issuing IDs. For health plans not ready to accept NPIs, something must be done to ensure the existence of a provider identifier valid to those health plans. WEDI recommends that UPINs and other identifiers continue to be issued to providers during the two or three year implementation period permitted by the HIPAA legislation.
Pages 25331 and following (Implementation)
The proposed rule describes seven possible choices for the NPI enumerator. Of those seven, two are identified as most viable : 1) enumeration by a Federally-directed registry; or 2) enumeration by a combination of Federal programs named as health plans, Medicaid Sate agencies, and a Federally-directed registry. Since BOTH options require the establishment of a Federally-directed agency, WEDI believes that the long-term objectives of administrative simplification are best served by choosing option 1 and eliminating the potential confusion, redundancy and cost of having the enumeration function being carried out by a large number of other entities.
This is particularly critical since the NPI is expected to be a unique identifier, and WEDI believes that uniqueness cannot be assured in a multi-enumerator environment.
WEDI recognizes the challenge of funding this option. We noted that the UPIN/Transoccidental model seemed to work well except for timeliness problems, and we suggest that this model be mirrored for the NPI registry process. It is also suggested that the registry be a not-for-profit, publicly accountable organization rather than a governmental agency, possibly a cross-industry organization. In general, Federal funds should provide start-up money, and then the organization should evolve into being self-supporting.
Finally, WEDI recommends that for either choice, on-line, phone and fax access should be available options for users.
Page 25322 (Implementation)
The proposed rule requests comments on DHHS s projection that about 20% of providers would seek enumeration through a federally directed registry (assuming option 2 was selected). At this point, WEDI does not challenge the accuracy of that projection.
Page 25332 (Implementation)
WEDI recommends that the chosen enumerator(s) take advantage of the data bases of professional organizations wherever feasible to speed enumeration and reduce costs.
Page 25333/2 (Implementation)
The proposed rule raises a series of questions regarding projections, costs, funding, and administration of the national provider file system. Specifically, on page 25333, comments are requested regarding: a.) appropriate methods for funding the NPS under option 2; b.) the burden that various options for financing the selected enumeration process might impose on the industry; and c.) possible ways to reduce the costs of enumeration. WEDI believes that answers to those questions will not come from the comments to the proposed rule which are submitted by individuals and organizations. Rather, WEDI believes that representatives of affected industry segments should come together with representatives of DHHS to examine, analyze and choose appropriate alternatives. As noted above, WEDI is uniquely qualified to convene and facilitate such meetings and to assist the Department in reaching consensus.
Page 25335 (Data)
As noted above, WEDI endorses the choice of a single Federally-directed registry to enumerate providers. If that choice is not selected in the final rule, WEDI notes that it will be important to maintain and display the history of NPI updates, either in an archive established for that purpose or in the database itself. If an archive accessible to qualified users is not maintained, then the database itself should show all update history, including which enumerator updated which fields on what date. However, if there is only one enumerator or if each enumerator maintains an accessible archive, then the database itself need only show the date and enumerator of the last update.
Page 25335/1 (Data)
WEDI suggests that the language of the first paragraph of page 25335 be modified to clarify that the clearinghouse is not solely responsible to ensure that it has the provider s NPI, and that no transaction ought to be sent unless the provider and the clearinghouse have communicated adequately to ensure that the clearinghouse has all the information necessary to generate a fully HIPAA-compliant transaction.
Page 25336 (Data)
The proposed rule solicits comments on the data elements proposed for the NPF. WEDI generally concurs with the proposed rule s classification of mandatory and optional elements, but believes that the identification of specific elements is best left to the industry and can be obtained by group meetings such as proposed earlier. Nevertheless, WEDI wishes to note that it endorses several key criteria for data element selection. Such elements should be: 1) required for enumeration; or 2) valuable to the industry as a whole in the transmission, receipt and processing of electronic transactions. WEDI does not endorse the capture and maintenance of data elements that are used for statistical purposes only or are required only for selected users. Finally, WEDI recommends that the business rules be established, and a final determination on mandatory and optional elements be made prior to issuing the final rule.
Page 25336 (Data)
The proposed rule request comments on the minimum set of data required to uniquely identify each type of provider (e.g., individual or organization). While the table of elements on page 25335 is reasonable, WEDI recommends that final determination be made by the industry through a WEDI-facilitated process as proposed above.
Pages 25336-7 (Data)
The proposed rule discusses what it characterizes as major questions relating to the NPS s requirements for: 1) provider practice addresses; and 2) group and organization data. WEDI has the following responses to the four specific questions listed on pages 25336 and 25337 of the proposed rule.
The NPS should capture one practice address and one mailing address for each provider.
The NPS should not assign a location code to each practice address in a health care provider s record.
The NPS should not link the NPI of a group provider to the NPIs of the individual providers who are members of the group.
There should be no distinction made between the data collected and maintained for organization vs. group providers.
Therefore, based upon these answers, WEDI strongly recommends the selection of Alternative 2 on page 25337, specifically noting that we: a.) agree with the implication of Alternative 2 that the NPS should not link individuals with organizations/groups; and b.) recognize that the endorsed alternative would not assign location codes, and not link individuals with groups.
Page 25338 (Dissemination)
WEDI recommends that the NPF be able to accommodate as many Provider s Other Names as are accommodated by the X12N transaction sets and include the X12 Provider Taxonomy s qualifier to define the type of Provider s Other Name.
Pages 25338/9 (Dissemination)
The proposed rule identifies two dissemination levels for information from the national Provider File. WEDI believes that there should be three levels. The first level (Level I) would include only the enumerator(s). Their right to the data would be unrestricted. The second level would be providers and health plans (Level II), and their access to data would be restricted to only that data which is essential for the timely and accurate processing of their health care transactions. The third level would be the general public (Level III), and they would have access only to provider name and NPI.
WEDI believes that limiting dissemination access is a sound business decision which both reduces the overall costs of the NPS while ensuring that all interested parties have access to the information on an appropriate need to know basis.
WEDI further recommends that the cross-reference to replacement NPI and the date of deactivation be included in the NPF and made available to users.
Page 25338 (Dissemination)
WEDI recommends that the cost of establishing and maintaining the registry(ies) and database be funded from a combination of federal funding (e.g. new budget lines or existing budget lines from the UPIN initiative) and fees for usage (including fees charged to providers for uses other than the establishment and proper maintenance of their NPI) that are reasonable and related to the costs and benefits of such usage.
Note that this explicitly suggests that usage fees not be limited to the costs of producing the data but can be linked to the costs and value of establishing and using the NPS.
WEDI discussed the possibility of utilizing the same (or a similar) mechanism that generates the UPIN to generate both the UPIN and the NPI simultaneously, provided the timeliness problem with the current UPIN mechanism can be eliminated.
Page 25339 (Dissemination)
Regardless of what data is released to those with access to the NPF, WEDI recommends that it initially be made available on virtually all types of media & including paper, CD ROM, the Internet, diskette, tape and cartridge. Regional or other subsets of the file should be made available as requested.
WEDI recommends that the enumerator(s) update the file at least daily. A file of the changes should be made available for electronic download on both a daily and weekly basis. For hard media such as CD ROM, diskettes, etc., both the NPF applicable to the user s level and an updates-only file should be available monthly.
WEDI further recommends that a standard be adopted and used for an on-line inquiry/response for verification or validation on a single provider. We believe that such a query capability and standard format may be considerably more useful and cost-effective than having industry participants constantly search through replicated databases which may be neither accurate nor up-to-date.
.Page 25339 (Dissemination)
WEDI recommends that enumerators/registry offer to authorized health plans, providers or other entities to accept inquiries and generate reports on matches, including reporting the NPI on those matches. The enumerator/registry would do this on a fee for service basis. Other services should also be available for a fee including initial files for populating a health plan s provider directory (bulk) and ongoing capability for updating and verifying.
Page 25340 (Section VII: Collection of Information Requirements)
The proposed rule would require that each health care provider that has an NPI forward updates to an NPI enumerator within 60 days of the date the change occurs. While recognizing that some lag in communication from provider to the enumerator is unavoidable, WEDI believes that the proposed 60 day timeframe is excessive. WEDI recommends that the proposed rule require that changes be communicated in a more timely fashion.
In concluding our comments regarding HCFA-0149-P, WEDI wants to take this opportunity to express our gratitude to the various federal government employees and others outside of the government (including WEDI s own Policy Advisory Group members) who have worked so long and so hard to prepare the proposed rule on these very complex transactions and issues. With their publication, our industry has taken a significant step toward the realization of the benefits of administrative simplification that Secretary of Health and Human Services Dr. Louis Sullivan and the first members of WEDI articulated in 1991. We are now eager to take the next steps in this process. Certainly, that includes clarifying or expanding upon any of these comments during the upcoming review period and offering any other assistance that is requested and appropriate to ensure the timely preparation and publication of the final rule.
Sincerely,
Richard P. Caliri
Chairman, WEDI
cc. WEDI Board of Directors
WEDI Policy Advisory Group Co-chairs
James A. Schuping, WEDI Executive Vice President
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