NRPM: Standard Health Care Provider Identifier. a. Health care providers.


Health care providers that conduct electronic transactions with health plans would have to begin to use the NPI in those transactions. Health care providers that are indirectly involved in electronic transactions (for example, by submitting a paper claim that the health plan transmits electronically to a secondary payer) may also use the NPI. Any negative impact on these health care providers generally would be related to the initial implementation period. They would incur implementation costs for converting systems, especially those that generate electronic claims, from current provider identifiers to the NPI. Some health care providers would incur those costs directly and others would incur them in the form of fee increases from billing agents and health care clearinghouses.

Health care providers not only would have to include their own NPI on claims, but they would also have to obtain and use NPIs of other health care providers (for example, for referring and ordering). This would be a more significant implementation workload for larger institutional health care providers, such as hospitals, that would have to obtain the NPIs for each physician practicing in the hospital. However, these health care providers are accustomed to maintaining these types of data. There would also be a potential for disruption of claims processes and timely payments during a particular health plan’s transition to the NPI. Some health care providers that do not do business with government programs may be resistant to obtaining an NPI and providing data about themselves that would be stored in a national database.

Health care providers would also have to obtain an NPI and report changes in pertinent data. Under one of the enumeration options presented in this preamble, current Medicare providers will receive their NPIs automatically, and other health care providers may be enumerated in this manner to the extent that appropriate valid data files are available. New health care providers would have to apply for an NPI. This does not impose a new burden on health care providers. The vast majority of health plans issue identifiers to the health care providers with whom they transact business in order to facilitate the electronic processing of claims and other transactions. The information that health care providers must supply in order to receive an NPI is significantly less than the information most health plans require to enroll a health care provider. There would be no new cost burden; the statute does not support our charging health care providers to receive an NPI.

After implementation, health care providers would no longer have to keep track of and use different identifiers for different insurers. This would simplify provider billing systems and processes and reduce administrative expenses. A standard identifier would facilitate and simplify coordination of benefits, resulting in faster, more accurate payments. Under option 2 of the enumeration options, (see section IX.K.2.d. of this preamble, on enumerators), many health care providers (all those doing business with Medicare) would receive their NPIs automatically and would be able to report changes in the data contained in the NPS to a single place and have the changes made available to many health plans.