Use Case 20: NPI-TIN mapping for Meaningful Use reporting

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Requirements

Use case summary


Description

  1. Make it possible to measure performance of a provider group, even for physician-level MU metrics. For each NPI (provider ID) show which TIN (org ID) that NPI falls under at the time of metric calculation. Currently, this can't be deduced from the elements in the Public Use Files. Hospitals should be included for this request.
  2. It's also valuable to know which NPIs were eligible for MU, but didn't submit to take advantage of it.
    • Note: These NPIs could also have a hardship exception

Value

  • Value to industry/public: Org-level metrics creates organizational accountability for the performance of all their docs. Knowing non-compliant NPIs within a TIN makes it possible to calculate success rate in MU attainment. It's also valuable to understand this mapping for hospitals.
  • Limitation: The lifetime value of this is only through 2017. At that point, due to MU sunset phase-outs, only payment adjustment at NPI-level (not TIN) will be relevant. (For example, if NPI works for 5 orgs, they don’t know where MU happens.)
  • Value to customer: Provide actionable insights to provider groups who sign up for the service.

Customer

Current data and limitation

  • Data source: Public Use Files (broken into multiple zipped files, due to size): NPI, Program Year, Payment Year, Attestation Success Date, multiple core measures (with numerator and denominator)
  • Challenge:
    1. Doesn't show TINs to which these NPIs were mapped
    2. Shows only NPIs that attained MU. We also want those who were eligible, but didn't submit.

Specifications

  • Fields:
    • NPI
    • TIN (or proxy unique ID for it, name of provider org + state hq)
      • It's acknowledged that an NPI can be mapped to multiple TINs at once
      • Ideally, hospitals should be included
    • snapshot date
  • Update frequency: 12 months, same as reporting period
  • Joins between datasets: N/A

Solution

Short term workaround

  • Submit a FOIA request for the "payment adjustment file":
    • TIN-to-NPI matching exists for “payment adjustment file”. These are already being generated for internal use anyway.
    • To get list of provider organizations that got audited for MU, look for occurrences of “MU audit” or “meaningful use audit” in this file
    • Tip: You can check the results for completeness and accuracy against the Medicare Individual Provider List dataset. But it's missing TIN or practice names (Current fields: NPI, first, last, effective date, end date, opt out flag).

Long term solution

  1. TIN can be proactively added to the existing PUF (public use file) file above. Or generate a separate PUF with TIN, NPI, date
    • Unanswered question: What’s the system of record? Is it PECOS?
    • Tip: Check the results for completeness and accuracy against the Medicare Individual Provider List

  2. Ultimately, this data should reside on “Physician Compare”. NPI affiliations to medical groups and hospitals should be included.
    • Limitations:
      • It includes only physicians enrolled in Medicare.
      • There's a 3-6 month lag time to get new physicians in.
    • Physician Compare comes primarily from PECOS, which is checked against Medicare claims data.

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