Support individual providers and group practices

[slifty]

There are three basic types of user who might submit an enrollment application:

1. An individual provider who practices on their own.
2. A person representing a group practice submitting an application for the group.
3. A person representing an individual provider within a group practice.

PSM needs to support relationships between individual providers and group practice. In order to do this, PSM needs to updated in the following ways:

• [ ] Update the schema / data representation to support the relationships and minimize redundant / denormalized data.
• [ ] Update user interfaces to correctly render that data in reporting and data summary views.
• [ ] Update the application flow to effectively collect information about group practices / individuals.

Different states may have different rules for this relationship (e.g. one state may require that every member of a group practice have their own enrollment, while another state may allow practitioners to use the enrollment of the group.)

[slifty]

Some questions related to this issue:

• Does each individual practitioner in a group practice need to have their own enrollment?
• Does each individual practitioner need to submit their own enrollment? Could a central administrator fill out the form once and have it generate several enrollments?
• What happens when a practitioner is added or removed from a group practice, does this require a new enrollment?
• If an individual practitioner has their own enrollment and they join a group practice, do they need to submit a new enrollment for that group?
• If an individual is part of multiple groups do they need to submit an enrollment for each group?
• How do these rules vary from state to state?
• Can an individual ever have different practices in different group practices (e.g. a nurse in one practice, an acupunturist in another)
• Are there privacy concerns around group practice membership? For instance, should an administrator who adds an individual member of their group practice application be able to know what other group practices that individual is a part of?

Later, James added this related question:

• How do states handle entity providers or groups of providers. If you have 3 doctors in a private practice, each doctor gets an enrollment, but does the practice get one too? Does a hospital have its own enrollment so it can bill for, say, Tylenol? We have learned that this differs among states so we want more information.

[kfogel]

These are spot-on questions! Thanks, @slifty. We will raise them with domain experts in our call.

[kfogel]

Some answers:

(Thanks to Katherine Stewart of the Louisiana Department of Health and Darryl Hellams of Virginia Medicaid for taking the time to answer.)

• Does each individual practitioner in a group practice need to have their own enrollment?

  VA: YES

  LA: Only if the group wants to submit claims on behalf of the practitioner with that practitioner's NPI listed on the claim

• Does each individual practitioner need to submit their own enrollment? YES Could a central administrator fill out the form once and have it generate several enrollments?

  VA: NO

  LA: We're still using PDF applications in our current system, so there would be a separate app for each individual practitioner.

• What happens when a practitioner is added or removed from a group practice, does this require a new enrollment?

  VA: To be added - YES. To be removed is a maintenance request only.

  LA: If the practitioner is already enrolled with Medicaid and needs to be added to an existing group, we have a short 1 page paper form to link them. If the practitioner wants to be removed from a group they're already linked to, then they can use the same form. If the practitioner is not yet enrolled and wants to both become enrolled and be linked to a group, the practitioner completes a full application, along with the same form as an addendum (to link them to the group).

• If an individual practitioner has their own enrollment and they join a group practice, do they need to submit a new enrollment for that group?

  VA: YES.

  LA: No, just a one page request form (see above answer).

• If an individual is part of multiple groups do they need to submit an enrollment for each group?

  VA: YES

  LA: They use the same 1 page form mentioned above, and they can list up to two groups on the same page.

• Can an individual ever have different practices in different group practices (e.g. a nurse in one practice, an acupuncturist in another)?

  VA: YES

  LA: Yes, as long as they apply for and receive different provider numbers. Our billing system limitations means that providers with more than one provider type need a unique provider number for each one.

• Are there privacy concerns around group practice membership? For instance, should an administrator who adds an individual member of their group practice application be able to know what other group practices that individual is a part of?

  VA: NO. A group Administrator cannot see any members of another group unless they are also the group administrator of that group as well.

  LA: We do not disclose that, but the question does not come up frequently at all.

• How do states handle entity providers or groups of providers. If you have 3 doctors in a private practice, each doctor gets an enrollment, but does the practice get one too? Does a hospital have its own enrollment so it can bill for, say, Tylenol?

  VA: YES, the group practice must be enrolled 1st, then the affiliated doctors are enrolled and affiliated. Hospitals are enrolled as a single entity. They can also have a physician group as well, but this would require a separate enrollment. We have learned that this differs among states so we want more information.

  LA: They use the same 1 page form mentioned above, and they can list up to two groups on the same page.

[jasonaowen]

Thank you, @kfogel! This is informative.

Can you please clarify something for me?

Can an individual ever have different practices in different group practices (e.g. a nurse in one practice, an acupuncturist in another)?

LA: Yes, as long as they apply for and receive different provider numbers. Our billing system limitations means that providers with more than one provider type need a unique provider number for each one.

What does "unique provider number" mean here? Is that an NPI, or a state-specific number? If it is state-specific, what is it called, and how do providers obtain these additional numbers?