NPI – Potential Issues Related to Clearinghouse and Billing Service Practices

As part of efforts to fully implement the Nation Provider Identifier (NPI), Medicare contractors have begun calling providers who are not sending their NPI on claims or are sending incorrect NPI information. It has come to the attention of the Centers for Medicare & Medicaid Services (CMS) that:

• Some clearinghouses may be stripping the National Provider Identifier (NPI) off the claim prior to its submission to Medicare for claims processing. Clearinghouses may be adding the NPI back onto the Remittance Advice, so that providers are unaware that their NPIs are being removed prior to being sent forward.
• Some billing services (or “key” shops) are not putting the NPI on the claim, contrary to provider instructions.
• Some clearinghouses are not forwarding carrier NPI informational claim error messages designed to providers designed to help the provider understand the problems Medicare is encountering in attempts to crosswalk the NPI to legacy identifiers.

Medicare Contractors are turning on edits to begin validating the NPI/legacy pair against the Medicare NPI Crosswalk. If the pair on the claim is not found on the crosswalk, the claim will reject. Stripping the NPI submitted by a provider from the claim adversely affects Medicare provider incentive cash flow, payers that receive crossover claims, and the efforts of Medicare to fully implement NPI.

If you are a Clearinghouse or billing service that is stripping or not sending the NPI, Medicare would like to better understand the reasons behind this practice as well as the expected timeframe during which this will continue to occur.

About the Author

Reed Tinsley CPA

This article is written by Reed Tinsley, a Houston, TX-based CPA with over 30 years of experience advising physicians and medical practices across Texas and the United States. Reed holds certifications as a Certified Valuation Analyst (CVA), Certified Healthcare Business Consultant (CHBC), and Certified Financial Planner (CFP), specializing exclusively in the healthcare sector. He is a published author, nationally recognized speaker, and trusted advisor to physicians on accounting & tax, practice management, and financial planning. Schedule a Free Consultation.