This is
a David and Goliath story. It’s about how the seemingly insignificant NPI can
fight medical fraud and positively impact effective medical management. Most in
Workers’ Compensation have either not heard of the NPI or consider it
irrelevant. Yet the NPI is a powerful factor in medical management and medical
fraud detection.
The NPI
The NPI
is the National Provider Identifier assigned by CMS, Centers for Medicare and
Medicaid to individual medical providers and organizations that deliver medical
services. The NPI is required for billing Medicare and Medicaid. Individuals
and groups must include their NPI on bills submitted. Without it, they are simply
not reimbursed.
If the
NPI is required for Medicare and Medicaid reimbursement, it follows that most,
probably all, medical doctors have a NPI number from CMS. The problem is that
most Workers’ Compensation payers do not ask for the NPI, do not require it,
and when the NPI is available, do not record it.
Why bother?
The
value of the NPI is that it uniquely identifies individual medical doctors. It
carves out individual treating physicians in groups, organizations and
facilities. Without the NPI associated with individuals, all those in a group
are lumped together under the organization’s NPI or, worse, the entity’s Tax
ID. This matters.
Distinguish individuals
The
ability to parse individuals from groups in the data is essential to fair and
adequate performance analysis. Individual differences evidenced in the data can
be distinguished, even within a group. This is essential to creating quality
preferred provider lists and networks. It is also indispensable for leveraging
the data to create a teaching platform for improving provider performance in
Workers’ Compesnation.
Training
Physicians
should be given the opportunity to see themselves portrayed in graphic reports
comparing their performance to others. Like everyone else, they want to look
good. They are high achievers. The graphic presentations are targets or guides
for improvement when followed with progressive reports. Simply paying attention to a treating doctor in this objective manner will result in positive behavior change! Using the comparative data for training purposes is invaluable, however, success depends on accurately identifying individuals in the data using the NPI.
Specialties
Another
valuable use of the NPI is to assign medical specialties to individuals. Professional
specialties can be obtained electronically from third party databases using the
NPI. Specialty is yet another data element missing in most bill review and claim
system data. But if the NPI number is available, specialties can be derived.
Specialties
are important so that treating doctors are compared to other doctors who are similarly
prepared and licensed. The argument from doctors that they only treat the more
difficult cases is nullified when they are compared only to others in their
specialty. The best example is pain management specialists who really do treat
the more difficult cases. Their performance should always be compared to other
pain specialists.
Fraud by NPI
Unfortunately,
there are those who twist the positive aspects of the NPI for fraudulent
purposes. Close examination of the data reveals less reputable medical doctors
and other providers obtain multiple NPI numbers, using them in different
locations or situations to deliberately obfuscate the data.
When multiple
NPI numbers are fraudulently used, the door is open to undetected duplicate
billing. Moreover, systems cannot recognize overall performance for the
individual. Their performance is fragmented across various NPI’s. In order to accurately
analyze performance for an individual, all treatment incidences should be
combined for one practitioner, thereby creating a critical mass of data for
that individual.
Much ado
While
some will think the focus on NPI is much ado about nothing, the reality is the
opposite. NPI numbers on all medical bills is essential. Payers should insist
on it. In fact, reimbursement should be withheld until the correct information
is included on the bill.
Impact on medical management
Treating
doctors not only drive direct medical costs, but also indemnity costs, return
to work, and disability ratings at the end of the claim. They can also
influence legal involvement. Consequently, finding the best doctors and
avoiding the bad ones is critical.
The way
to determine who should be included in quality medical provider networks is to analyze
past performance based on the data. The only way to accurately analyze
performance is to identify individual treating doctors in the data and evaluate
their performance based on the relevant performance factors. Correct NPI numbers
included on medical bills are essential.
What to do
Workers’
Compensation payers must require a correct NPI number on all medical bills.
This is not an outrageous demand and does not add to costs. However, it will
take attention and initiative on the part of those involved. The benefits are
too great to miss this simple, yet powerful opportunity.
The
simple little NPI is a powerful element in Workers’ Compensation medical
management. It is the David that can effectively and affordably fight the
medical fraud Goliath.
Karen Wolfe is the founder and President of MedMetrics, LLC, an Internet-based Workers’ Compensation analytics
company. MedMetrics offers online apps that link analytics to operations,
thereby making them actionable. karenwolfe@medmetrics.org
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