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What is the NPI number?

 By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

 

November 22, 2024


You may have heard of the "NPI" number. 

What is it and why should you care? Let's explore!


A. What is it?


  • The NPI means: "National Provider Identifier". 

  • It is a 10 digit number that any single individual or corporation in the US who renders 

    medical services or provides supplies must obtain. 

  • These are individuals such as doctors, therapists, practitioners, nurses, physician 

    assistants, even dentists and chiropractors, or anyone with some form of a medical or clinical license.

  • But an NPI is also required for providers who are organizations, physicians' groups, 

    nursing homes, home health agencies, medical durable equipment sellers, hospitals or one of those large corporations that own a number of hospitals, urgent care clinics,

    dialysis or infusion centers. 

  • The NPI number functions as an ID to clarify who actually renders the medical service 

    and who should get paid for it. 

  • The NPI was created to simplify the claim process for insurance companies to know who rendered the service and who should be paid (and not have to try and identify the right Dr John Smith out of potentially 100s of them), while screening out potential fraud.


B. Uses


  • As the healthcare system is nothing but a giant computer system, using codes instead of names is a very efficient way to transfer and transmit clinical as well as financial data. 

  • One of the NPI feature is to indicate if a physician or an entity is active or not. 

  • It provides a contact information, mailing and physical address 

  • And last but not least, the taxonomy indicates what type classification and specialization that specific provider or entity is licensed in. If a claim's NPI shows a specific type of license but the practitioner bills a service or diagnosis incompatible with it, the

    insurance system will reject the charge as "not within the scope of license" or "not payable for this provider".

C. Why should you care?


  • I know you will say that this matter is between the medical provider and the insurance.

    Well, yes... except when you have to pay an out of network provider directly. You get an 

    invoice or a superbill, which you file with your own insurance to get reimbursed. 

    What I see is that too many invoices are incomplete and therefore will be denied. 

    And I don't care how many appeals you file and how many phone calls you make. If the NPI is not indicated or is incorrect, you will fail.

  • All medical providers must provide you with accurate and completed claim forms as part of their medical licensing requirements. It is one of your patients' rights, and definitely, it's a must in the insurance reimbursement process.

  • If the provider is a sole proprietor, meaning their tax ID number is actually their social security number, one NPI is enough. The person providing the service and the one to pay are the same.

  • But if the medical provider belongs to a medical group or is employed by/under a

    corporation, two NPI numbers are needed on each invoice: one to identify who

    actually rendered the service and the entity that needs to be paid for it. 

  • Any denial for lack of an NPI number should automatically be sent back to the medical 

    provider or their biller for a correction. 

  • Better yet, once you receive the invoice or superbill, make sure those NPIs are there 

    before you submit it to your insurance company.

  • Otherwise, don't hesitate. Speak to your doctor or your therapist or their biller to get 

    things done right and avoid reimbursement delays and hassles to get your insurance to finally pay. 

 


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computer code lines



Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

 

(424) 999 4705 - F (424) 226 1330 -@martine brousse 2024 @ the medical bill whisperer 2024™

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