National Provider Identifier Errors That Cause Claim Denials
Errors in the national provider identifier can cause claim denials and delay reimbursements, making accurate billing essential for healthcare providers.
There are many problems that medical billing professionals have to contend with when making the insurance claims, and some of them are annoying to such an extent that the denials that occur due to national provider identifier mistakes. These apparent easy to form mistakes may cause delayed payments, loss of revenue, and administrative overheads that impacts healthcare practices of any size. Being aware of typical errors related to NPI and the ways of preventing them are the keys to having a healthy revenue cycle.
What Is a National Provider Identifier?
National provider identifier National provider identifier is a 10-digit identification number allocated to healthcare providers in the United States. This identifier was mandated by the Health Insurance Portability and Accountability Act (HIPAA), which was a replacement of various identification numbers that were formerly required by various health plans. Centers for Medicare and Medicaid Services (CMS) proposed the NPI system to unify the provider identification in all the insurance companies and healthcare transactions.
All healthcare professionals who pass health information in electronic form are required to get an NPI. These comprise physicians, nurses, dentists, chiropractors, therapists and other individual practitioners and also organizational providers such as hospitals, nursing home and medical groups.
Common National Provider Identifier Errors
Missing or Incomplete NPI Numbers
Another mistake that is most common is submitting claims without a national provider identifier or with an incomplete number. Each of the claims must have both the rendering provider NPI (the party who delivered the service) and the billing provider NPI (the party delivering the claim). The absence of either of these identifiers leads to an automatic rejection of claims.
Transposed or Incorrect Digits
Basic mistyping of data may lead to major troubles. In case the staff members transpose or input the wrong numbers, the claim will be rejected since the NPI does not correspond to the provider information in the database of the payer. Even one digit is wrong, and all the identifiers are invalid.
Using Inactive or Deactivated NPIs
Retired or switched specialty or closed practice healthcare professionals might have inactivated NPIs. Claims that are submitted using inactive identities are rejected instantly. Equally, newly qualified practitioners who are yet to be assigned their NPI are not yet in a position to have valid claims made before their identifier is activated.
Mismatched Provider Information
Insurance companies ensure that the national provider identifier corresponds to the provider name, specialty and the practice location on file. In the event that this information is not in line, the claim is rejected. This usually occurs when the providers change their name, relocate to a different location, or change their specialty without informing all the concerned payers.
Individual vs. Organizational NPI Confusion
There are two types of NPIs (Type 1 (individual) and Type 2 (organizational)). Misunderstanding on the particular identifier to use in certain fields of claim leads to errors in processing. As an example, an individual NPI in the rendering provider field will be denied by using an organizational NPI.
Common Denial Codes Related to NPI Errors
Awareness of denial codes enables the billing departments to detect and address the national provider identifier problems in a short time. The most prevalent codes are as follows:
| Denial Code | Description | Resolution |
|---|---|---|
| CO-16 | Claim lacks information or has submission/billing error | Verify NPI accuracy and resubmit |
| CO-18 | Exact duplicate claim/service | Check for duplicate NPI entries |
| CO-27 | Expenses incurred after coverage terminated | Confirm NPI is active and valid |
| CO-50 | Non-covered services | Verify NPI matches provider specialty |
| CO-96 | Non-covered charges | Ensure correct NPI type is used |
| N130 | Invalid or missing provider identifier | Add or correct the NPI |
| N132 | Provider taxonomy not valid | Update NPI taxonomy information |
Additional Claim Adjustment Reason Codes
| CARC Code | Meaning | Action Required |
|---|---|---|
| 1 | Deductible amount | Review NPI for accuracy |
| 8 | Procedure code inconsistent with provider type | Verify NPI specialty matches service |
| 11 | Diagnosis inconsistent with provider type | Confirm correct provider NPI used |
| 15 | Authorization number missing, invalid, or does not apply to billed services | Check authorization tied to correct NPI |
| 31 | Patient cannot be identified as our insured | Verify rendering provider NPI |
| 252 | Invalid/missing number or invalid format | Correct NPI format and number |
Impact of National provider identifier Errors on Revenue Cycle
The error of the national provider identifier generates a shock throughout the revenue cycle. Rejected claims take time on the part of staff to investigate, rectify and re-enter. This is a process that makes payment slow by weeks or even months. In some practices, it has been reported that 5 to 15 percent of the total rejections of claims is as a result of NPI-related denials.
In addition to the late payments, such mistakes augment the administrative expenses. The billing personnel will be required to reach out to insurance companies, confirm information and make appeals. The duration of these activities may be allocated to more useful undertakings such as patient care coordination or proactive denial prevention.
Relationships with players can also be ruined in case of repeated NPI errors. Insurances can put practices that are characterized by a high error rate under additional examination, causing increased durations of processing all claims made by that provider.
Best Practices for Preventing National provider identifier Errors
Implement Regular Database Updates
Having the current database of any provider NPIs utilized in your practice. Set up quarterly checks of all identifiers to ensure that the identifiers are up to date. Deactivate NPIs under all circumstances and provide new information on providers as soon as possible.
Use NPI Validation Tools
You can find a free NPI registry through the National Plan and Provider Enumeration System (NPPES) where you can check the provider information. Make this tool a part of the working process to verify identifiers prior to filing claims. There are also numerous practice management systems that have a built-in NPI validation feature.
Billing Staff of Trains, Thoroughly
Make sure that every billing staff is aware of the value of the correct entry of national provider identifiers. Conduct frequent training on frequent mistakes and how to evade them. Establish uniform protocols of inputting provider data to your billing system.
Conduct Pre-Submission Claim Scrubbing
Check NPI errors before submission using automated claim scrubbing software. The tools would determine missing, invalid, and mismatched identifiers enabling you to rectify them before they lead to denials.
Maintain Clear Communication Channels
Create communication channels between billing and clinical personnel. The billing staff should be notified immediately about any changes in NPI as providers join or leave your practice, the provider updates credentialing status, or the provider changes specialty.
Monitor Denial Trends
Monitor and trace denial patterns in order to find repeated national provider identifier problems. In case some of the providers or services have a consistent NPI-based denies, search the cause, and provide specific corrections.
Steps to Correct NPI-Related Claim Denials
In the event of a denial associated with national provider identifier errors, you should take the following steps:
- Check the denial notice and determine the problem with the NPI.
- Check the right NPI in the NPPES registry.
- Ensure parity in the provider information of all the systems.
- Fix your practice management system mistake.
- Revise the claim using the correct information.
- Re-file the claim based on payment requirements.
- Record down the error and solution to make later reference.
The majority of the payers permit resubmission of the corrected claims within a certain period usually 30-90 days after the date of first refusal. Loss of this window can lead to loss of revenue and rejection of claim on a permanent basis.
National Provider Identifier Management Technology Solutions
The advanced billing software available today has advanced capabilities to reduce the errors of national provider identifiers. With electronic health record systems, it is possible to automatically fill out NPI fields depending on the rendering provider chosen. Provider credentials are verified by real time eligibility verification tools against payer databases prior to the submission of claims.
The practice management platforms based on the cloud have centralized provider directories which update simultaneously across all the modules. When you make changes to an NPI or provider detail in one location, the changes are made across the whole system, eliminating discrepancies.
Claims processing is now coming under artificial intelligence and machine learning technology application. These systems are informed by the previous denials, and are able to anticipate the likely NPI errors in advance, prior to submission and correct them.
Why Choose Billing Care Solutions?
Billing Care Solutions provides a full-service medical billing to help you maximize your practice revenue by removing claim denials. Our professional staff is aware of the issues of the national provider identifier development and introduces strict quality management measures to maintain correct claim filing.
We make your life easier by providing better technology platforms, real-time eligibility verification, and proactive denial prevention mechanisms to ease your workload and enhance your bottom line. Our certified billing experts are always up to date with the evolving payer demands and regulatory changes, and you can be assured that you will not get any hassles.
We provide clear reporting, account management, and successful outcomes which make healthcare providers concentrate on patients and leave the revenue cycle to us. Collaborate with Billing Care Solutions and realize quicker payments, denials reduction, and better financial results of your practice.
Conclusion:
The error of national provider identifiers is a potential avoidable cause of claim denials, which companies in the area of healthcare cannot afford to disregard. Organizations can optimize their revenue cycle by limiting NPI-related denials and enhancing their performance through implementation of quality verification systems, staff training, use of technology solutions, and proper provider databases.
The trick to success is to take the NPI accuracy as a priority, and not an afterthought. A culture of billing excellence is established by regular audit, constant education, as well as active prevention of errors and benefits the practice as well as its patients by increasing the speed of claims processing and enhancing financial health.
