Case Studies
National Provider Identifier Crosswalk System
Client: Centers for Medicare & Medicaid Services (CMS)
The Maricom Team developed the NPI Crosswalk System for the Centers for Medicare & Medicaid Services to provide critical support to the HIPAA-mandated initiative to implement a single unique identifier for each provider, the National Provider Identifier.
The Problem:
Every year, CMS processes an estimated 1.2 billion Medicare fee-for-service claims, inquires, and appeals for over 100,000 different health care providers.
CMS computers identify the health care providers using ID numbers when they process these electronic health care transactions. Unfortunately, different health care programs often used different ID, or “identifier,” numbering schemes. In addition, providers often used multiple identifiers within a single numbering scheme when delivering health care services to a patient, generating complex ID relationships. Various identifier types add further complications to the mix. As a result, multiple identifiers proliferated in the data stored across hundreds of CMS databases.
To help fix the issue, Congress in 1996 passed the Federal Health Insurance Portability and Accountability Act (HIPAA). HIPAA required that a universal National Provider Identifier (NPI) be used for each health care provider. However, to continue referencing the extensive stores of data already in their databases, CMS needed some way to match the new NPI to the multiple “legacy” identifiers already in use. The correct crosswalk of these identifiers is critical to ensure proper payment and payment reporting, medical review, utilization review, and fraud and abuse detection so that no stakeholder is negatively impacted.
The Challenge:
Develop a solution that would provide reliable, accurate matching of old identifiers to new – without slowing up the processing of claims, inquiries and appeals to enable CMS to deliver comprehensive, accurate, and up-to-date health care information.
The Solution: Crosswalk for Mapping IDs Across Heterogeneous Databases
CMS engaged Maricom to design, develop, and implement a matching system known as a “crosswalk”. Crosswalks enable search engines to search effectively across heterogeneous databases. They typically do so by mapping the “metadata” identifiers from one data framework to other data frameworks. But the complexity posed by the NPI initiative rendered any “out-of-the box” solution out of the question. More than simply a static set of tables, the NPI crosswalk solution would have to employ a processing repository with “dynamic” matching capabilities. Sophisticated algorithms, or mathematical sets of rules, would need to be developed that would enable a search engine to match relationships and equivalencies between multiple metadata formats at the same time.
Maricom recognized that up-front planning, requirements gathering and business analysis would be critical to the success of the project. The Maricom Team worked closely with CMS staff to capture the business objectives behind the creation of the NPI Crosswalk System, and to map out which systems the identifiers operated on, who used them and for what purpose.
After determining the system’s requirements, a concept of operations “ConOps” document was prepared to describe the NPI Crosswalk System from the viewpoint of any individual or organization who would use it. Maricom implemented all phases of this project, from initial assessment through implementation and ongoing operations and maintenance. To ensure the delivery of a robust and scalable solution that met both short and long-term CMS requirements.
The Outcome:
The NPI Crosswalk has enhanced the interoperability of CMS databases, empowering CMS with an enterprise-wide solution. The solution is flexible for other end-users and can be updated, changed, or augmented to assist with end-user requests for information.
The NPI Crosswalk System (NPICS) serves as the only trusted source for mapping NPI to Medicare provider identifiers and enables CMS to provide critical support to the HIPAA-mandated initiative to successfully implement a single unique identifier for each provider.
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