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The MedMetrics blog provides comments and insights regarding the world of Workers’ Compensation, principally, issues that are medically-related. The blog offers viewpoints regarding issues affecting the industry written by persons who have long experience in the industry. Our intent is to offer additional fabric, perspective, and hopefully, inspiration to our readers.

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Thursday, March 6, 2014

The Secret Power of the NPI

by Karen Wolfe

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.

For more information on this related topic, view, “Why Poor Data Quality is Not an IT Problem”.

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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