Minnesota HIPAA Collaborative

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Minnesota HIPAA Collaborative

• What We Know About Atypical Providers
• Ann Wandersee
• MN Department of Human Services

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Who is eligible for an NPI?

• NPI regulation published 1-23-04
• Covered healthcare providers must obtain an NPI
  by compliance date and must use the NPI in
  covered transactions
• A covered health care provider is a healthcare
  provider that meets the definition in paragraph
  (3) of the definition of covered entity at 45 CFR
  160.103

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Who is eligible for an NPI?

• All healthcare providers are eligible to obtain
  an NPI
• Healthcare providers
• Hospital, critical access hospital, skilled
  nursing facility, CORF, hospice, home health
  agency
• Healthcare services
• Physician services, hospital services, drugs,
  psychologist services, home dialysis services,
  DME and medical supplies, ambulance diagnostic
  services, eyeglasses, PT, OT, ST etc.

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What is an atypical provider?

• From the preamble of the Final Rule
• Individual or organization that provides
  nontraditional services that are indirectly
  healthcare related
• Must determine if the individual or organization
  provides any services that fall within definition
  of healthcare
• If no, and does not provide other services or
  supplies that bring it within the definition of
  healthcare provider then not a healthcare
  provider under HIPAA and not eligible for an NPI

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Atypical Service Examples

• Non-emergency transportation
• Physical alterations to living quarters for the
  purpose of accommodating disabilities
• Vehicle modifications
• Some Medicaid Home and Community Based Services
• Habilitation
• Respite services

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How to Determine if you are an Atypical
Provider

• Must evaluate the service as well as the entity
  providing the service
• Consider the definition of a healthcare provider
• Does the organization provide or bill healthcare
  services as defined in law in the normal course
  of business?
• If the service is not a healthcare service and
  the provider does not meet the definition of a
  healthcare provider then an NPI will not be
  assigned

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WEDI SNIP White Papers

• WEDI and NMEH created a list of entities that are
  considered to be atypical, including
• Custodial care facilities
• Adult day care provider
• Assisted living facility
• Massage therapist

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Purpose of the WEDI SNIPWhite Paper

• Education
• Document types of atypical providers
• Gain industry consensus and agreement on certain
  types of providers and the need for an NPI
• Includes list of provider examples
• Describes the services they render
• Review alternative approaches to enumeration

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Atypical Providers Today

• Health plans assign legacy provider
  identification numbers for all providers
  including atypical providers
• Some atypical providers are currently paid
  through an organization
• MN DHS assigns provider numbers for atypical
  providers contracted by Medicaid MCOs

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How will atypical providers be enumerated?

• Some may obtain an NPI
• Continue to use legacy numbers
• Enumerate on a national, regional or health plan
  level

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Atypical Provider Enumeration

• In the absence of a regional or national
  enumerator, atypical providers
• Face diverse enumeration rules and regulations
  for each payer
• Variances in definition of atypical vs. covered
  healthcare
• Different billing rules for organizations
  providing both non-medical services and covered
  healthcare services
• Billing requirements for border providers will be
  non-standard

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Atypical Provider Enumeration

• Impact on Coordination of Benefits
• Lack of standardization
• Impact on crossover processes
• Costly for provider and health plan
• Difficulty determining duplicate billings

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DHS Approach to Atypical Providers

• DHS has determined which providers are atypical
  based on the WEDI white paper
• Create a 10-digit number with a leading alpha
  character based on the current 9-digit provider
  identification number
• Put edits in place so an atypical provider can
  not submit an NPI to DHS
• 10-digit number will be communicated to atypical
  providers
• DHS will not support the WEDI Dual Use Strategy
  for atypical providers

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Regional Approach

• DHS would enumerate all atypical providers in MN
• DHS 10-digit number could be used by all MN
  payers
• Each payer would still require enrollment in
  their program
• MN payers are reviewing the proposal
• Difficulty in consistent nomenclature and
  defining provider types
• Difficulty matching providers from one payer to
  another

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Regional Enumeration

• Discussions have been limited to payers in the MN
  HIPAA Collaborative
• Other payers need to be included in the
  discussions
• Payer impact analysis needs to be completed
• Payer systems would need to be modified
• Communication plans need to be developed
• Is there enough time?

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National Enumeration

• National enumeration
• Unique number
• Provides administrative savings
• Facilitates COB
• Provides consistent definition of atypical
  providers and non-traditional services
• Provides a database of numbers
• Database is maintained

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Alternate Solutions

• National enumeration is the best option
• Best meets provider and payer needs
• Providers and payers need time for systems
  modifications
• Payers need contingency plans
• Timing is everything

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Resources

• MN HIPAA Collaborative
• www.mnhippacollab.org
• Workgroup for Electronic Data Interchange
• www.wedi.org
• Ann Wandersee
• ann.wandersee_at_state.mn.us