Alert: Medicare starting to reject claims with NPI discrepancies

The AMA is alerting physicians that Medicare must be able to match a physician's appropriate PIN to his or her correct National Provider Identifier (NPI) and may reject claims if a match cannot be made.

Prior to Sept. 4, 2007, most Medicare carriers permitted claims to process through their computer systems even if an appropriate match between the physician's NPI number and their old legacy billing number(s) could not be made. However, as of September 4, Medicare has started to "turn on" the edits that previously allowed these claims to process.

The AMA strongly encourages physicians to immediately check with their billing office to determine what, if any, error reason codes have been returned over the summer. These codes could indicate an NPI mismatch in the Medicare system. Physicians who use a clearinghouse should check to ensure that the NPI or these reason codes are not being stripped off of their claims.

Note: Medicare must be able to match single, incorporated physicians-those who have an LLC or other incorporated business arrangement. These physicians must have two NPIs-one for themselves and one for their corporation. In some cases Medicare may have originally assigned these physicians one PIN rather than the two that are now needed to match a physician to his or her correct NPI number. In these cases, re-enrollment in Medicare is required. In addition, physicians in large group practices who may have multiple Medicare PINs could also experience claims interruptions if there are matching problems.

The AMA is aggressively advocating for the Centers for Medicare and Medicaid Services (CMS) to alleviate the significant administrative burden these developments will place on physician practices. A joint letter from the AMA and Medical Group Management Association was sent to CMS on September 11, 2007 requesting a reversal of this policy along with more time to re-enroll in Medicare so they can obtain the appropriate PIN and avert claims processing interruptions.