The National Plan and Provider Enumeration System (NPPES) is a centralized database of provider information maintained by the Centers for Medicare and Medicaid (CMS). It is the largest publicly available database of provider information available. But how good is the NPPES database?
Let’s look at some of the pros and cons that the NPPES database provides. As we wrap up, we’ll consider how we can use the NPPES database to make our provider data better.
NPPES Database Overview
When healthcare providers need to bill health insurers or government agencies like CMS for their services, they must use a National Provider Identifier (NPI) to do so. This uniquely identifies the provider. It is intended to make healthcare transactions – like claims, authorizations, and referrals – more standardized. This leads to greater efficiency in healthcare operations when providers are compliant.
NPIs are assigned by the NPPES database. When a healthcare provider needs to conduct transactions like filing claims, they will register to obtain an NPI from the NPPES database.
In addition to NPIs, the NPPES database requires providers to provide certain information. It also has several additional data elements that can be optionally provided. The NPPES database collects the following information:
- National Provider Identifier (NPI)
- NPI Type which will indicate whether the owner of the NPI is an individual person or an organization
- Provider’s name and any aliases (such as DBAs for organizations or professional names for individuals)
- Provider’s primary practice location, mailing address, and any additional practice locations
- Provider’s taxonomy codes including one primary taxonomy and any number of secondary taxonomies
- Provider licensure information including states and license numbers
- Additional provider identifiers such as Medicaid IDs
- Provider contact information such as email address or website
Overall, the NPPES database offers a substantial amount of information. However, there are challenges with information that is capture, frequency of updates, and accuracy.
NPPES Data is Self-Reported
The NPPES database has a lot of information about millions of healthcare providers. However, a database is only as good as the quality of the data within it. In that sense, NPPES data can be a mixed bag.
NPPES data is self-reported by providers. This means that it is up to the individual or organizational provider to verify their records within the database regularly. They are also responsible for updating their records when there are changes. These changes could include a change in the primary practice location, mailing address, names, taxonomy codes, and the like.
The NPPES database keeps track of the last time each record was updated. Some providers are diligent about maintaining their information. Other providers may not update their records for years on end.
The self-reported nature of the NPPES database also means that a health plan or payer organization cannot rely solely on the NPPES as a source of truth. External verification of the information is required to maintain accurate internal records.
This is especially true of taxonomy or specialty information. There is no mechanism within the NPPES database to verify that a provider is licensed for the specialty they indicate. Any organization that employs or pays healthcare providers must perform its own due diligence through the credentialing process. This includes using Primary Source Verification (PSV) to confirm the provider’s credentials with appropriate medical boards and educational institutions.
NPPES Data Lacks Critical Data Elements
Another factor to consider when using the NPPES database is that important information is not captured. This is particularly the case with large provider organizations. In some cases, the information is not captured at all within the database. In other cases, the information is generally incomplete.
The most important information that is lacking is a view of the relationships between providers. Many individual providers practice under one or more provider groups or facilities. The NPPES database does not allow providers to specify the medical groups that they practice under at any given location.
Since the COVID pandemic, many providers have begun to offer services via telehealth offerings like Teledoc or Dr. On Demand. Providers licensed in multiple states may have locations in one state while practicing remotely in others. The NPPES database does not currently provide information regarding telehealth practices for providers.
Many large provider organizations operate numerous locations that may include hospitals, ambulatory surgery centers, specialist offices, imaging centers, laboratories, and primary care offices. The NPPES database allows for the designation of subparts of an organization, but this is primarily just an indicator and does not “point” back to the parent organization.
This leaves health plans to rely on information received from their contracted providers to maintain accurate payment information and provider directories. Payers may need to use multiple avenues to identify accurate information including:
- Data gleaned from recent claims submissions
- Provider rosters received from contracted provider groups and facilities
- Targeted provider directory audits based on random sampling
- Data aggregation vendors or clearinghouses
How to Use the NPPES Database
Although the NPPES database is imperfect, it is the best source publicly available source that we as an industry have. CMS has indicated as much in a memo from January 2020. CMS encouraged plans to leverage the NPPES data to improve the reliability of provider directories. Additionally, they encourage health plans to modify their provider contracts to require regular reviews and updates to NPPES data.
While it is encouraging that CMS is taking a strong stance that NPPES appears to be the way of the future, it still leaves significant gaps for health plans. CMS has indicated that the data elements captured in NPPES represent 91% of provider directory review errors that they have identified. However, this does not mean that simply using NPPES data would correct those errors. If NPPES data is not complete and current, the errors will persist.
That said, health plans can leverage NPPES as an additional source to inform the accuracy of their provider data. At Decipher Solutions, we recommend the following approach:
- Use NPPES to confirm the validity and type of NPI numbers. This can help you identify providers who are no longer practicing as well as ensure that providers are assigned the correct NPI number in your system.
- NPPES can be used to backfill missing taxonomy or specialty information. This should be done cautiously. For non-participating providers, NPPES can generally be relied upon. For participating providers, we recommend maintaining a crosswalk from NUCC taxonomy codes to your internal specialty lists.
- Use NPPES to backfill missing information. For example, if you have an address on file that matches what is captured in NPPES, you may capture phone or fax numbers that are missing from your records.
- NPPES can be used to carefully correct provider names. This includes misspellings or “backwards” entry such as the first name being entered in the last name field.
Health plans should not blindly accept NPPES data into their internal databases. They should establish rules for when they will allow NPPES to override what they have on file. Those rules should be applied systematically to internal data sets.
Getting More From NPPES
Maven One’s Rule Engine module (MORE) allows health plans to get more value from the NPPES data set. With our Smart Fix technology, we can help health plans to establish and systematically apply those rules. This results in cleaner provider data after the first pass and clear guidance for data that may require more remediation.
Additionally, Maven One can assist health plans in monitoring for timeliness in NPPES updates. This gives health plans additional tools to monitor compliance as they implement contractual requirements for providers to maintain accurate data. That includes automated reminders to providers to perform updates and monitoring of records that have not been updated in a timely manner.
Connect with us today to find out more about how Maven One can help you get better provider data quickly and easily.