Creating ting a Pa Path for Reliabl able e Provider der Information rmation NAHDO’s 35 th Annual Conference August 25, 2020
Objectives Examine Provider Complexity in APCD Data Discuss Provider Index vs Directory Understand Value and Importance of NPI and NPPES
Defining a Provider What is What is the provider a provider? universe? 3
Defining a Provider What is What is the provider a provider? universe? Context of the inquiry Define the use case Define the unit of analysis for specific provider-level inquiries 4
Provider Elements on APCD Claim Records Service Billing Rendering Facility Attending Operating Referring Prescribing Pharmacy Location Organizations Organizations Organizations Individuals Individuals Individuals Individuals Organizations & Individuals & Individuals Provider Num, Provider Num, Location Num, Provider Num, Provider Num, Provider Num, NPI, Provider Num, NPI, NPI, NPI NPI NPI NPI Tax ID, NPI, Tax ID Tax ID DEA Tax ID Name Name Name Name Name Name Name Name (L or Org) (F, M, L, S) (Location, (F, M, L, S) (F, M, L, S) (F, M, L, S) (F, M, L) (Org) L or Org) Street Address Street Address Address (City, State, ZIP) Specialty, Specialty Entity Type L = Last Name; F = First Name; M = Middle Name or Initial; S = Suffix (e.g., Jr., Sr., III) 5
Two Organizing Approaches Provider Index Inventory of the provider ‘units’ submitted on APCD records + provider details Provider Directory Provider nesting & other relationships, analytical groupings + enhanced provider details 6
APCD Provider Index: Where to Start? Service Billing Rendering Facility Attending Operating Referring Prescribing Pharmacy Location Organizations Organizations Organizations Individuals Individuals Individuals Individuals Organizations & Individuals & Individuals Provider Num, Provider Num, Location Num, Provider Num, Provider Num, Provider Num, NPI , Provider Num, NPI , NPI , NPI NPI NPI NPI Tax ID, NPI , Tax ID Tax ID DEA Tax ID Name Name Name Name Name Name Name Name (L or Org) (F, M, L, S) (Location, (F, M, L, S) (F, M, L, S) (F, M, L, S) (F, M, L) (Org) L or Org) Street Address Street Address Address (City, State, ZIP) Specialty, Specialty Entity Type L = Last Name; F = First Name; M = Middle Name or Initial; S = Suffix (e.g., Jr., Sr., III) 7
National Provider Identifier HISTORY DATA ELEMENTS WHAT IT IS VALUE 10-digit HIPAA Administrative NPI Available at the national level intelligence-free Simplification Standard for Entity type (‘1’ Individual; ‘2’ Available publicly, at no cost, identifier for identification of covered Organization) in a machine-readable format providers of healthcare providers in and through a website query Provider name(s) healthcare services administrative and financial tool transactions Business mailing and practice Assigned through Monthly updates available for location street addresses the National Plan Created to “improve the full replacement files and Provider efficiency and effectiveness of Other identifiers (Medicare, Wide range of potential uses Enumeration electronic transmission of Medicaid, DEA, etc.), licensing System (NPPES) health information” and taxonomy information 2004 (Jan): NPI Final Rule Sole proprietor, organization published subpart, parent organization 2005 (May): NPI becomes Dates: enumeration, last effective update, deactivation, reactivation, certification 2007 (May): Compliance deadline Deactivated NPIs 2007 (Sep): Dissemination through NPI Registry, NPI Downloadable File 8
APCD Provider Index: Processing Steps Data Provider Provider Data Submission Validations Composite ID Details PROVIDER Eligibility Standard NPI NPPES Data INDEX Code Lists Elements Medical, Dental, (e.g. current (refreshed Pharmacy NPPES list of quarterly in Claims providers) the APCD Data Payer-Based Validation Warehouse) Provider Rules Files 9
Example: Hospital Provider FACILITIES, DEPARTMENTS INDIVIDUALS General Acute Care Hospital General Acute Care Hospital Swing Beds Physician Physician Supplier Nurse C Nurse D A B E Physician Internal Medicine Specialty Care Services PHYSICAL LOCATIONS Location X Location Y Location Z 10 10
Hospital Providers for a Specific Use Case Scenario 1 | All Hospital Locations Combined General Acute Care Hospital Swing Beds www.comparemaine.org Healthcare transparency website; shows the average Internal Medicine Physician Services cost of common healthcare procedures at different facilities in Maine. Phys A Phys C Phys E Phys F MHDO and HSRI worked directly with hospital Phys B Phys D providers to: • Validate the list of billing NPIs to include in analysis Scenario 2 | Hospital-Location X; Hospital-Location Y • Validate the facility location(s) address(es) General Acute Care Hospital Confirm the consumer-friendly display name • • Decide on analytical grouping for cost estimates: Swing Beds General Acute Care Hospital rollup across all locations (Scenario 1) or separate Internal Medicine for each location (Scenario 2) Physician Services Revisit and confirm accuracy of all the above during Phys A Phys C • Phys E Phys F each release of CompareMaine Phys B Phys D 11 11
Building a Provider Directory Standards and reference information (e.g. facility, professional, state or national inventories) Audience (e.g. health systems, healthcare consumers, researchers) Methodological considerations PROVIDER PROVIDER (e.g. universe or subgroup, provider detail elements to INDEX DIRECTORY include and maintain, custom or standard provider groupings) Time and resources investment Context of the Inquiry | Use Case 12 12
Challenges & Limitations Provider Index Provider Directory • Absent NPIs • Difficulty in determining relationships between providers • Using NPPES for the provider name is not always straightforward • Time and resource intensive (e.g. occasionally the alternate “doing • Maintenance may not be business as” name is preferred) sustainable • NPPES may be incomplete • “Does it scale?” (e.g. determining primary taxonomy where not indicated) • NPPES recency of updates 13 13
Challenges & Limitations UPDATE RECENY IN NPPES 14 14
Recommendations To build reliable provider information: • Monitor APCD submissions to detect data quality issues and changes over time and between payers; refine intake validations • Improve data users’ knowledge and understanding of the provider complexity in APCD • Use opportunities to promote the NPPES and to increase its completeness and accuracy • Continue to explore pathways towards a national Provider Directory using best practices, streamlined validation processes, and additional provider resources (e.g., state or national databases for provider licensure information, DEA database) 15 15
Contributors Kevin Rogers SENIOR BUSINESS SYSTEMS ANALYST, HSRI Kristin Battis RESEARCH ASSOCIATE, HSRI Sharon Ulery RESEARCH ANALYST, HSRI Melissa Hillmyer PROJECT MANAGER, HSRI Leanne Candura DIRECTOR – POPULATION HEALTH, HSRI
Thank nk You. u. Ioana Crisa san DATA SCIENTIST icrisan@hsri.org
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