What’s in a Name? Warning: You Could Be at Risk

So, you want to be a doctor? No problem. Four years of undergrad, a decent score on your MCATs, four years of med school, residency, an internship – and that’s if you don’t choose to be a specialist. Now you want to go into the real world and pay off your quarter-million in student loans? But wait, there’s more! 

First, you have to get your NPI, or National Provider Identification number. To do this, you will fill out the NPI Application/Update Form (CMS-10114). In section 3.D., you will be asked to provide your taxonomy or specialty codes, and you can list up to four, with the primary specialty listed first. Once assigned, this information is stored in the National Plan and Provider Enumeration System, or NPPES, database.

Then you have to go through another process with another application so you can be credentialed specifically for Medicare. This is called PECOS, or the Provider Enrolled Chain and Ownership System. Of course, as you probably know, you have another form that needs to be filled out. This is Centers for Medicare & Medicaid Services (CMS) form 855, and it can have a suffix of A, B, I, R, O, S, or POH, depending on whether you are an individual, clinic, organization, etc. For form 855I, which is for individual physicians and non-physician practitioners, under section 2.D.1, you will be asked to designate your primary and secondary specialty from a list of dozens, without any restriction as to how many boxes you can check.

Assuming that you now have your NPI number and have been credentialed for Medicare, you can start billing payers for services you provide to your patients. But let’s say that you want hospital privileges so you can treat your patients in a hospital. Now, you will have to apply again and go through another review process. And once again, in many of the applications, you will be asked to provide your primary and sometimes secondary specialty, if applicable. 

Congrats! Now, what is your specialty? Well, the practice sees you as some given specialty, and the hospital gave you privileges with some specialty designation, and your NPI number is associated to some specialty, and under the PECOS system you are identified as some specialty, but the question is, are any or all of those correct, and do any of them match? The answer is, not always. In fact, in a study of over 15,000 physicians we conducted, we found that some 5 percent of respondents reported inconsistencies between the specialty they claimed and the specialties identified in the NPI and PECOS databases. In some cases, there wasn’t a match between any of them.

So, why is this a problem? Well, from a compliance perspective, it’s because so much of compliance risk assessment is dependent on peer-based benchmarking. Even the fraud prevention system, with its advanced statistical and predictive analytics techniques, depends on stratifying data by specialty. For example, the Comprehensive Error Rate Testing (CERT) study conducts analyses by specialty. 

More specifically, it identifies average error rates by specialty and then breaks down reasons for those errors, also by specialty. For example, table I reports improper payments by provider type for each claim type.  

So if you are benchmarking yourself as an internal medicine physician against other internal medicine physicians but you are really a cardiologist or gastroenterologist, then your numbers are going to be wrong, and so will be your risk assessments. 

The bottom line? Get it fixed. Check the NPPES and the PECOS databases and make sure that they not only match, but that they list your correct specialty.

And that’s the world according to Frank.