Healthcare provider data and medical marketing lists

About the National Provider Identifier (NPI)

The purpose of the National Provider Identifier (NPI) program is to assign a unique national identification code to all providers of health care whose services fall under HIPAA, including individuals, organizations and groups of individuals. Included are physicians, nurses, nurse practitioners, dentists, optometrists, pharmacists, physical therapists, pharmacists, physician group practices, acute care hospitals, specialty hospitals, nursing homes, ambulatory care facilities, hospices, home health agencies, ambulance services, clinical labs, DME suppliers, pharmacies, etc. The number would be used in standard transactions by all health plans eliminating the current system of multiple numbers for a single provider. (Take a look at included healthcare providers.)

 The NPI Final rule requiring providers to be included in the data, and to update within 30 days of any change.

A work group consisting of representatives from the private sector, Federal and State agencies came together in 1993 to define the NPI and establish a system for assigning the numbers to every U.S. HIPAA-covered entity. They developed the National Plan and Provider Enumerations System (NPPES) to operate as the central database for the NPI. While the word "Plan" in the system's name would imply that health plans are also included in the data, this extension of the system has not yet materialized.

The National Provider Identifier (NPI) is a Health Insurance Portability and Accountability Act (HIPAA) Administrative Simplification Standard. It replaces a fragmented system of identifiers that included UPINs, Medicare PINs, state Medicaid numbers, provider identifiers assigned by thousands of health plans, and other identifiers—all of which were needed to disambiguate a particular provider across the healthcare system. The NPI is a unique identification number intended to solve this problem. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.

As outlined in the Federal Regulation, The Health Insurance Portability and Accountability Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.

Providers must apply for their NPI number (a process called "enumeration"), which is generally accomplished using an online tool provided by the Centers for Medicare and Medicaid Services (CMS), a division of the U.S. Department of Health and Human Services (HHS). Information supplied by the provider is kept in the National Plan and Provider Enumeration System (NPPES) database. Information includes in-depth contact information, specifics regarding the provider's practice or facility, and other identifying codes such as Medicare and Medicaid identification numbers and the deprecated UPIN.

Providers may choose to use a written form that can be submitted by mail. Download the NPI enumeration form to review the kinds of information collected in the NPPES database.

The NPPES database does not include a provider's PECOS status (enrollment to bill Medicare), or whether or not the provider is on the federal List of Excluded Individuals/Entities (LEIE) from the HHS Office of Inspector General (OIG); however, CarePrecise compiles this information into the CarePrecise Access and CarePrecise Select database products. The NPPES database, as released by CMS, is of a size and format that is not ready for use on ordinary computers in standard office software, such as Microsoft Office® products; CarePrecise makes the complete NPPES data, along with added information from PECOS, LEIE and other sources, available for such use.

 

Accuracy of NPI Data

CarePrecise uses the NPI Registry (NPPES) data as one of its primary sources because of the comprehensive nature of the data. By law, every HIPAA-covered U.S. healthcare provider must be in this database, and they must update their record within 30 days of any change. The penalty for false information is severe:

18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly or willfully falsifies, conceals, or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing.

"Penalties for Falsifying Information" section of the HHS NPI registration information publication.

In a study conducted by Mathematica Policy Research and published in the Journal of General Medicine, investigators found that The NPPES database scored best at 94% accuracy, the SK&A at 92%, while the AMA Masterfile had significantly lower rates of correct address information across all specialties scoring only 54%. 

"NPPES and SK&A had the highest rates of matching mailing address information, while the AMA Masterfile had low rates compared with the NPPES... the NPPES and to a lesser extent, the SK&A file, appear to provide reasonably accurate, up-to-date address information for physicians billing public and [private] insurers."

"The Results Are Only as Good as the Sample: Assessing Three National Physician Sampling Frames," Journal of General Internal Medicine. 2015. Catherine M. DesRoches, Dr.P.H., et al.

Providers have learned that keeping their NPI data up to date can shorten reimbursement cycles, and improve relationships with payers as well as consumers of healthcare.

Read more about accuracy comparisons and improvements in provider data accuracy here...


Questions About the NPI

Almost everything you ever wanted to know about the NPI is here.

CMS provides an NPI search tool for looking up providers' NPI numbers.

CarePrecise provides a listing of the data fields from the NPPES (NPI registry database) that are included in CarePrecise healthcare provider data products.

CarePrecise cannot access or edit NPI registry records. To update your record, as required within 30 days of any change, visit the NPPES website and login using the credentials that were created with the NPI registration.

 

Obtaining the NPI Database

Review CarePrecise Access Complete for the full NPI database, with added data from related federal healthcare provider databases.

CarePrecise Gold and CarePrecise Platinum both offer the complete database, plus special tools for segmenting providers by specialty, geographic radius, wealth, urban/rural, and other parameters. Platinum contains additional extended data.

NPI data can be obtained for individual states; see CarePrecise Access State.

Historical NPI data is also available from CarePrecise. More than 100 monthly data releases are available. CarePrecise also archives the NPPES dissemination files from CMS. Contact us for details on purchasing historical physician data and historical data on all U.S. healthcare providers.

 

Additional Resources

Refer to the CMS field descriptions for technical descriptions of the data fields. CarePrecise uses abbreviated field names.

Refer to the CMS field codes document for details on field codes used in CarePrecise.

Access Complete - Full U.S. healthcare provider database, updated monthly.

Access State - State by state healthcare provider data, updated monthly.

Select Hygiene - Service that provides enriched data for clients' in-house databases.

Select Targeted - Permits clients to select specific provider specialties and facilities in particular geographic areas, and many other selection criteria.

CP ListMaker - Desktop application that allows clients to create highly targeted lists of providers for industry research, clinical trial development and marketing applications, using the Access Complete data. It is also available bundled with the data.

Wikipedia NPI page.