CCN and PAC ID to NPI: Crosswalk between the NPI Registry and Hospital and Group Records

The federal Centers for Medicare and Medicaid Services (CMS) publishes a wide range of information on U.S. hospitals, which all carry the unique identifier, the CCN number (CMS Certification Number)*. On the other hand (which often seems to not know what its counterpart is doing), CMS also publishes the frequently updated NPPES database (National Plan and Provider Enumeration System), commonly known as the NPI Registry, which uses the NPI number (National Provider Identifier) as its unique identifier. While hospitals and other medical organizations will have only one CCN Number, they are required to have at least one NPI number, and they're permitted to have as many as they like (and they do seem to like quite a few). 

And, between these two ID systems, the CCN and the NPI, ne'er the twain shall meet.

CarePrecise has developed a sophisticated system to "roll up" an organization's NPI-numbered records with its CCN number (and with the PAC ID for practice groups, which stands for "PECOS Associate Control ID"). This mighty trick produces some eye-opening data, such as contact names and titles, license information, specializations, market data added by CarePrecise to NPI records, and the ability to crossmatch groups to their members and hospital affiliations, directly from their NPI numbers. It also permits integration across the complete line of CarePrecise provider data packages, and all of the information that CarePrecise collects or creates and then merges to the NPI records.

Currently, these CarePrecise rollups (or "crosswalks" if you prefer) are the only available such thing in a relatively comprehensive dataset. The full rollup of all medical facility NPI numbers is available for hospitals, and a single "priority" NPI number is currently available for practice groups, with a full rollup of all PAC ID-to-NPI linkages in development with a tentative release date in May 2023.

The hospital CCN-to-NPI crosswalk is part of the Authoritative Hospital Database (APD), and the Group PAC ID-to-NPI link is part of the Authoritative Physician Database (APD) and CarePrecise Platinum.

The "rolling up" is made possible by several CarePrecise innovations, starting with the CoLoCode (co-location code) affixed to almost every provider in the 7 million+ record CarePrecise master reference database. To fill in additional linkages, The CarePrecise HealthGeo geocode dataset, containing latitude and longitude for all 8.5 million+ provider records, which can readily be used to link data between data suppliers for a variety of purposes.

* The CMS Certification Number has replaced the term Medicare Provider Number, Medicare Identification Number or OSCAR Number. The CCN is used to verify Medicare/Medicaid providers for survey and certification, assessment-related activities and communications. Note that CarePrecise includes the old OSCAR Number in its CarePrecise Complete and CarePrecise Advanced/Platinum datasets, if reported by the provider in their NPI record(s) or available through third-parties, but this is a small fraction of records, and the OSCAR numbers have changed, hence the need for a CCN-to-NPI crosswalk.

HIPAA-Covered Providers Top 4 million

With the August, 2013 data release, a new milestone has been reached in the U.S. healthcare industry. There are now 4,021,049 healthcare providers covered under HIPAA, of which 900,126 are physicians.

Over 1 million entities, mostly physicians and physician groups, are enrolled to bill Medicare, according to the PECOS Ordering and Referring report.

Added just this month were 30,578 new NPI records. Over the past 60 days, changes were made by healthcare providers on 127,972 NPI records.

The CarePrecise Access Complete dataset includes all of these records.

Healthcare Fraud Recovery $4.2B for 2012

Attorney General Eric Holder and HHS Secretary Kathleen Sebelius released a report today indicating that for every $1 spent on healthcare fraud and abuse recovery, $7.90 has been returned to the treasury over the past three years. With the Obama administration making recovery a top priority, this is the highest level of return in the 16-year history of the program.

Health Care Fraud Prevention and Enforcement Action Team (HEAT) was created in 2009 to reduce fraud, waste and abuse in the Medicare and Medicaid programs and to crack down on individuals and organizations that are bleeding the system. Last year, the Justice Department opened 1,131 new criminal fraud investigations involving as many as 2,148 defendants. Convictions have been achieved on 826 defendants in fraud-related crimes during the year. In the same year, the department opened 885 new civil investigations.

In 2012, CMS began screening all 1.5 million Medicare-enrolled providers through the new Automated Provider Screening system. APS fingers ineligible and potentially fraudulent providers and suppliers prior to enrollment or revalidation. Nearly 150,000 ineligible providers have been eliminated from Medicare’s billing system so far. 

CarePrecise's standard database of healthcare providers includes a field that indicates providers who may still be active, but have been added to the federal List of Excluded Individuals and Entities, tying excluded providers to their NPI numbers.

Practice Group Data Now Part of CP ListMaker

Jan. 29, 2012 -- CarePrecise announces a major upgrade of its  CP ListMaker software that puts all 3.5 million U.S. healthcare provider records – including almost one million physicians – in reach for marketers. Now includes practice group data to help qualify sales leads.

Today we announced a new version of our popular CP ListMaker software, our desktop system that puts all of the 3.5 million healthcare provider records – including approximately one million physicians and tens of thousands of hospitals and ambulatory care facilities – at the fingertips of researchers and marketers. CP ListMaker allows users to pull tightly targeted lists of physicians and other providers based on criteria such as specialty, subspecialty, facility types for organizations, provider gender, wealth/poverty of service area, Medicare enrollment, and many more. The new version, CP ListMaker 3.5, unveils new practice group data, and does it in an interesting way.

Until now, it has been difficult to find data indicating provider’s practice groups. With new data now obtained from Centers for Medicare and Medicaid Services (CMS), combined with CarePrecise’s advanced record linkage system, CP ListMaker identifies practice groups, and can list all of the providers working at each practice location. 

The “Co-location codes” attached to each record make it possible to further qualify potential prospects for companies marketing to the medical community. Not only physician practices, but dental groups, behavioral services groups, and all other HIPAA-covered healthcare providers are co-location coded. The new CP ListMaker offers tools for using the new data. For example, to export a list of obstetric/gynecology group practices of between 3 and 20 members.

CarePrecise’s record correlation processes also make it possible to link providers’ PECOS and LEIE records with their NPI (National Provider Identifier) records ( http://www.careprecise.com/pecos-npi ), providing a rich master record ( http://www.careprecise.com/provider-data-linkage.htm ) that can be used to enrich or update customers’ existing databases. The PECOS data (indicating which providers are enrolled to be able to bill Medicare) has recently been redacted by CMS, now providing only a partial NPI number; however, our system restores the full NPI number. The federal List of Excluded Individuals/Entities (LEIE) database, which lists providers who have been barred from billing federal programs due to fraud convictions or other infractions, also has no unique identifier as distributed; however, CarePrecise links the LEIE data to the NPI data with each monthly update.

With or without a unique identifier, such as an NPI, EIN, UPIN or OSCAR -- or even a telephone number -- the CarePrecise master data management system, known as QoRelate® (http://www.careprecise.com/provider-data-linkage.htm ), can pull provider data together into a master record database from diverse sources. The company offers boutique record linkage services that can be used to merge data acquired during mergers and acquisitions, through cooperatives such as Health Information Exchanges, or from multiple in-house systems.

CP ListMaker is available as part of the CarePrecise Gold bundle, which includes CP ListMaker and the full U.S. healthcare provider database, or separately for customers who already subscribe to the CarePrecise data. The tool runs in Microsoft Access 2003, 2007 and 2010, and is provided open source, making all of the Access tools available to users.

RESOURCES:

CP ListMaker healthcare provider research and market targeting tools:
http://www.careprecise.com/cplistmaker

 

QoRelateMaster Data Management & Record-Linkage:
http://www.careprecise.com/provider-data-linkage.htm  

CarePrecise Gold (complete U.S. healthcare provider database with marketing and research tools):
http://www.careprecise.com/gold

 

Contact CarePrecise:
http://www.careprecise.com/contact

91 Charged With $295 Million Medicare Fraud

Ninety-one doctors, nurses and others were charged in a blockbuster sting operation, with arrests unfolding over three weeks and culminating in 70 arrests last week. In 2007, a strike force was set up between the Department of Justice and the Department of Health and Human Services to identify and build federal fraud cases to fight criminal abuse of federal healthcare programs. U.S. Attorney General Eric Holder said that arrests were made in eight US cities involving more than $295 million in stolen funds.

Almost half of those charged were part of a Florida ring that recruited healthcare providers to refer patients to a mental health center, in some cases threatening residents of a halfway house with eviction if they refused the unnecessary care. Another case involved $3.4 million in unnecessary physical therapy by two Brooklyn physicians.

On September 1, officials in Detroit charged 18 physicians, nurses, clinic owners and other medical professionals for submitting $28 million in false claims to Medicare. Just one day earlier, the owner of a Houston, Texas durable medical equipment business was sentenced to 97 months in prison for his role in a Medicare fraud scheme.

In all, the strike force, known as Health Care Fraud Prevention and Enforcement Action Team (HEAT), has charged 1,140 defendants who collectively have falsely billed the Medicare program for more than $2.9 billion.

When providers have been convicted of fraud and certain other infractions and delinquencies, their names are placed on the List of Excluded Individuals/Entities (LEIE) database. CarePrecise compiles this data into its comprehensive database of U.S. healthcare providers, identifying excluded providers' NPI numbers, phone and fax numbers.

Read the full story on the HHS website.

A Nut Too Tough to Crack?

One of the hardest problems in health IT is the effort to get data from different silos into a centralized database that can be searched as a single dataset. So, this is us announcing our new "linking and shrinking" technology, code named "Squirrel." What does it do?

Squirrel is a record-linkage and deflation system that pulls in data from multiple federal provider databases in various formats, makes them play nice together by linking everything up under providers' NPI numbers, preserves all the data but shrinks the file size down to about 9% of the original size, puts it in a format that can be managed in Microsoft Access or other garden variety database software, downloads it to our customers, and then does it all again fresh every month.

The technology is built on record-linkage methods developed over twenty years. Interesting trivia: The precursor to the current system was built in Microsoft Access 1.0 -- you remember it, the Introductory Package -- in 1992. While we don't share all the secrets, the basic trick involves pattern matching algorithms and a lot of processing time to handle more than 13 million rows of data, comparing each provider's records between all the sources. The end result is called CarePrecise Access.

We just sent out a press release about the whole thing.

Now you'll excuse us, as we have some more nuts to collect and crunch on.

Flaw in CMS Logic Causes Cost

When the NPI Final Rule (and all of its after-final rules) created the National Plan and Provider Enumeration System, there were many unknowns: Which datapoints would be released for the industry to use? loomed large. But another issue has come home to roost.

Organizations (Type 2 providers under the rule) were permitted to have as many NPI numbers as they liked, and they could structure their assignment of NPIs any which way. For instance, one hospital might get separate NPI numbers for each of its business units, while another got and NPI for each of its physical locations, another for each of the cluster of corporations, while some clever hospitals got an NPI for each reimbursement channel. And then of course, some hospitals got just one.

No problem with that -- the various business optimization strategies are interesting to observe, and surely make sense in their various contexts. The problem is that there is no primary NPI number per hospital or health system. That is to say, there is no way to know from the NPPES records which if any of the NPI records is a parent, and which is a child. Oh, of course, an army of human analysts can pore over the records and find 37 hospital NPI records each identifying, say, Mayonaise Health System as its parent. But a computer finds that task a bit difficult, since it will find many variations in the records, e.g.,

• Mayonaise Hospital
• Mayonaise Health System
• Mayo Hospital
• Mayo Hospitals
• Mayonaise Hospitals
• Miracle Whip Health
• and on an on

Thus, it becomes essentially impossible to say how many hospitals there are, even though we are looking at the complete set of federal records on hospitals. Had there been a primary or master NPI required for each General acute care hospital -- regardless of how many business units and other NPIs are involved, it would be possible to perform much more significant research on hospital service areas, densities, availability of care, duplication of services, and much more. (We've just started putting state-by-state physician and hospital counts on our home page at CarePrecise.com, but for now, we are able only to show the total of all hospital records -- 29,946 at present -- which is far more than the roughly 5,000 actual hospitals to whom all those records belong.)

The coyness built into the NPPES was more or less deliberate. American hospitals are a contentious lot, engaging in constant competition, and they did not want any more known about them than absolutely necessary. Coy data costs everyone money, and adds opacity to the healthcare system. Still, with the HospitalCompare project and our subsequent mining of all of these data sources, much can be learned, and the reach of each hospital organization can ultimately be published. Stay tuned.

Nearly 3000 Excluded Providers Still Practicing

You might wonder if, and if so, why, healthcare providers who have been convicted of Medicare fraud are still practicing medicine, writing prescriptions, and billing health plans (except, presumably, Medicare). Well, it's a good question. Apparently such a conviction may not get a provider's NPI deactivated.

For several months the number of providers that appear on both the HHS Office of Inspector General's excluded providers list and the current National Plan and Provider Enumeration System (NPPES) have hovered around 2,700.* But for December the number jumped to 2,925. Of that number, more than 1,400 are physicians.

For the past several months, CMS has dropped only 400 to 500 providers each month for various reasons; not all dropped NPI records are due to fraud convictions. Interestingly, the December NPPES dropped more than 1,000 records, while still including more than 2,900 providers listed in the LEIE (List of Excluded Individuals/Entities), the federal database primarily of healthcare providers convicted of fraud or other crime, for patient neglect or abuse, felony controlled substance conviction, or whose licenses have been revoked, suspended or surrendered. A small number of providers are included on the list for less serious reasons, including refusal to provide required information to HHS, and default on a federal healthcare education loan. An inquiry sent to CMS requesting information on the matter has not been answered.

Each month, nearly 30,000 new records are added to the NPI database, primarily representing new healthcare providers. On average, 33,000 records are updated (by the providers themselves in nearly every case). The December NPPES database includes 3,277,833 healthcare provider records. All HIPAA-covered U.S. healthcare providers are required to obtain an NPI record. For all practical purposes, a physician's NPI number, along with a DEA number, is required to write a prescription because pharmacies generally require them. Theoretically, at least, if a pharmacy could not find a valid NPI number, it could refuse to fill the prescription.

CarePrecise compiles federal healthcare provider data for use in research, clinical trial provider pool development, fraud prevention and marketing. Clients include health plans, educational institutions, drug companies, marketers, law enforcement, health systems and individual providers.
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* Source: CarePrecise research data. Methodology involves cross-referencing the two databases using proprietary algorithms to affix NPI numbers to providers in the fraud database; the fraud database (LEIE) does not include NPI numbers, making it difficult to track against practicing providers. Actual number of providers on both lists may be higher; the cross-referencing algorithm is used conservatively.