Use Case 16: 3rd party updating of NPPES

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Requirements

Use case summary


Description

This use case was originally entered to address the following concerns:

  1. I&A credential setup is not clear. After the initial account creation, there is zero explanation on next steps .
  2. The "Connections" program is not well documented. It was unclear how to submit the data, what had to be done authenticate, etc. Not clear what a 3rd party can do with provider daata. There's no information about method to modify data (such as web form, API, upload, email, fax, etc.)
  3. The data model is very limited and doesn't support the complexity of real world scenarios. Basically, a single provider has a single practice location. This is obviously not how the real world looks. A recommendation would be to allow a many-to-many relationship between people and places, and include a flag for "formerly" so that a history of movement and changes could be maintained.

Value

  • Value to customer: This capability would be a significant value-add for the provider groups who see the existing update process as too onerous.
  • Value to industry/public: NPPES is out of date and often incorrect. This information gets propagated to many other systems and applications on a regular basis, causing confusion for patients and administrative overhead for the industry.

Customer

  • Doctor.com

Current data and limitation

  • Data source: NPPES
  • Challenge: These are common questions from 3rd party surrogate organizations that would like to keep provider information up to date in the NPPES system.
    1. Is there specific paperwork 3rd party organizations need clients to sign that to authorize joint updating of their NPPES listing?
    2. Is there any specific paperwork that would be required for client to revoke that authority in the case that they wish to part ways with the 3rd party organization?
    3. Have there ever been any issues of liability that have arisen from a relationship like this?
    4. What are the various ways that the process of claiming and updating the listings can be streamlined (ie. could a 3rd party organization have a single login connected to all of the clients? Is there a standard fax form could be use? etc.)
    5. How can a 3rd party organization get an end-to-end walkthrough of the process?

Specifications

  • Fields: Same as those available in NPPES database
  • Update frequency: Ideally real-time, but at least monthly
  • Joins between datasets: NPI as primary key

Solution

Update via I&A

CMS’s Identity & Access (I&A) Management System is supposed to enable “streamlined access to NPPES, PECOS, and EHR” to both healthcare providers and their 3rd party surrogates.

Steps:

  1. An organization must first apply via I&A to be an "authorized surrogate".
  2. Obtain explicit permission from each provider they want to update.
    • Per FAQ: "Authorized & Delegated Officials are able to see all the Individual Providers who have approved the Group as their Surrogate. Staff need be given access to those records by an Authorized (AO) or Delegated Official (DO)."
    • For an individual provider to authorize an EFI provider, the individual provider must hold, on file with the EFI provider, a release allowing the EFI provider to alter their NPPES listing and include all of the legal language from the original.
  3. Updates for multiple providers at a time could be batched
    • As of September 2015, an organization reported partial success in transferring updates in bulk.
      • The organization was accredited to submit through an EFI, and uploaded an XML file via the login portal.
      • A technical limitation does not allow updating of NPIs for "sole proprietors" via the EFI process. If the "sole proprietor" NPI field is populated with "Y," then the EFI process cannot be used to update their NPI. If the filed is "N," "X," or empty, then the EFI process can be used.
        • Explanation of technical limitation: "Current operational rules do not allow sole proprietor NPIs to be updated via the EFI process. When originally designed many years ago it was expected that EFI would be used by large groups to support adoption by members of physician group practices or hospitals. It was expected that individuals on their own such as sole proprietor would not need to be updated in bulk. As the industry has progressed and providers have begun to use third parties to maintain records, we recognize this system limitation, and is something we will be looking to address as we move forward with NPPES in the future. There is not a definitive date for this change, however we do not anticipate anything before late 2016"
        • This is a recognized issue that CMS will be looking to address in the future, but date can be confirmed for when the issue will be addressed.
      • The updates appear to post to the NPPES database immediately and then propagate to the download files within a month. The one lag is the Enumerator takes a few hours to review the file for formatting errors.
  4. Support is provided: Contact the External User Services (EUS) Help Desk at 1-866-484-8049 or EUSSupport@cgi.com

Access NPPES data

Encouraging more frequent NPPES updates

  • Education for providers on heavy use of NPPES data by consumer facing companies

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