CMS recently released a guidance letter concerning if HIPAA rules would prohibit a health plan from requiring certain providers from obtaining an NPI where they don’t already have one. You can read the guidance letter HERE. The short answer is that a health plan may require a provider who doesn’t already have an NPI to obtain one for the purposes of recording their services in a claim. This is important for both claim accuracy and the ability for the health plan to monitor potential fraud, waste, or abuse (FWA). How so? Consider the following scenario.

A nurse practitioner (NP) under the employ of a skilled nursing facility (SNF) is performing services on patients in that facility. If the NP does not have an NPI because the claim is always submitted under the NPI of the SNF, the health plan has no idea which provider actually performed the service on the patient. This prevents the health plan from tracking billing aberrations such as an impossible number of hours in a day, or perform normal provider credentialing on the provider. Essentially, the health plan is blind to who is performing services on the member.

In order to do effective FWA detection, the health plan must have accurate and complete claim data. Context⁴ Healthcare always recommends that the health plan require providers to submit full and complete information on the claim, including the NPI of the service provider. This should be required before the health plan adjudicates the claim. Without it, the health plan’s assets are at risk.

Visit Context’s website to learn more about our full Health Plan Suite. These solutions help protect your plan from overpayments and help detect possible FWA. Context has been in the business of helping health plans achieve compliance since 1988, and we’re trusted by hundreds of payers around the country. Contact us at www.context4.com and fill out a “contact us” form, or give us a call at 800-783-3378. Let us help you protect your health plan.