Use Case 14: Link NPI and PECOS datasets

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Requirements

Use case summary


Description

Need ability to link NPI and PECOS datasets and compare against the address information on the claims in utilization data.


Value

  1. This base level of information accuracy is a prerequisite before a patient can do even a basic search (let alone one with insurance info, cost, quality, etc.) This is widely acknowledged, and every healthcare stakeholder participates, commonly through purchasing this data from the AMA or vendors like enclarity. [source: Reed Mollins @ Doctor.com]
  2. The provider data most sought is the PECOS data. That data has not yet been released by CMS. One important use case that would be enabled by exposing PECOS data via webservice is that Medicaid groups or other payers could quickly ascertain if a provider is a Medicare provider, thus making the vetting/screening process much simpler for many providers. [source: Alan Viars at CMS's Modernizing NPPES project]

Customer

Publishes quality metrics and reviews on doctors for use by patients. Also provides useful contact and background information.


Current data and limitation


PECOS data is not publicly available

  • Challenge:
    • It’s difficult to match across these datasets and not clear how to resolve discrepancies in addresses. Doctors don’t update their NPI listings, but CMS pays the bills and they get sent to addresses, so the claims have additional address info.
    • An NPPES program called "Connections" via I&A (Identity & Access) System may enable 3rd parties to update NPPES and PECOS. But it's not obvious how to sign up.

Specifications

  • Fields: NPI number, address1, address 2, city, zip, phone, fax
  • Update frequency: quarterly or yearly

Solution

  • NPPES data is outdated.
    • One reason is that CMS doesn't require that it be updated and providers typically don't have enough incentive to update it.
    • The current NPPES security implementation makes it difficult for providers' office staff to update the database. It would be efficient for an office staff member to be able to update multiple providers at a time.
  • PECOS data is more up to date than NPPES.
    • It must be updated at minimum every 5 years, although in reality gets updated much more often, due to it's functional nature.
    • Additionally, "PECOS is periodically throughout the day" from NPPES data. (Source: https://pecos.cms.hhs.gov/pecos/login.do, 5/20/2015). There's no indication that the updates flow the other way, from PECOS to NPPES.

In an effort to prepare the prescribers and Part D sponsors for the December 1, 2015, enforcement date, CMS is making available an enrollment file that identifies physician and eligible professional who are enrolled in Medicare in an approved or opt out status. The file contains production data but is considered a test file since the Part D prescriber enrollment requirement is not yet applicable. An updated enrollment file will be generated every two weeks and continue through the December 1, 2015 enforcement date. The file displays provider eligibility as of and after November 1, 2014 (i.e., currently enrolled, new approvals, or changes from opt-out to enrolled as of November 1, 2014). Any inactive providers or periods of inactivity for existing providers prior to November 1, 2014, will not be displayed on the enrollment file. However, any enrollments that become inactive after November 1, 2014, will be on the file with its respective end dates for that given provider. For opted out providers, the opt out flag will display a Y/N (Yes/No) value to indicate the periods the provider was opted out of Medicare. The file will include the provider’s: • National Provider Identifier (NPI); • First and Last Name; • Effective and End Dates; and

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