diff --git a/docs/new-sector-compliance-targets.md b/docs/new-sector-compliance-targets.md index 028031a..2caf01a 100644 --- a/docs/new-sector-compliance-targets.md +++ b/docs/new-sector-compliance-targets.md @@ -267,3 +267,139 @@ committing volume; these vendors change rates and gate some behind sales. - Always personalize with the detected deficiency + a **QR code / short URL** to the relevant free lookup tool — that QR is our tracking + conversion bridge, the same role the email CTA plays today. + +--- + +## 6. NPI Compliance Programs, "Expired" Signals & Suggested Rates + +### What we actually know is expired/dead (honest breakdown) +NPPES alone has **no license/cert/revalidation expiry date**. The only hard +"dead" status in the file is **NPI deactivation**. Real dateable "expired" +signals come from FREE companion databases joined to NPPES by NPI or name. + +| Source | What it proves is expired/wrong | Hook | +|---|---|---| +| NPPES (deactivation cols 39-41) | NPI deactivated — cannot bill | NPI reactivation (HARD) | +| NPPES (Last Update col 38) | Record stale (not "expired", a nudge) | NPPES update | +| **CMS PECOS Revalidation list** | **Medicare revalidation due/overdue date (5-yr)** — the real dateable hook | Revalidation filing (flagship) | +| **OIG LEIE** | Provider EXCLUDED from federal programs | Exclusion remediation (urgent) | +| **SAM.gov exclusions** | Debarred / additional exclusions | Screening + remediation | +| State medical board lookups | License itself expired (not in NPPES) | License renewal | + +> Flagship analog to FCC RMD recertification = **CMS Medicare revalidation due +> date**, joined to NPPES by NPI. That is the genuine "your X expired" signal. + +### Programs to sell (ranked by trigger defensibility) +1. Medicare PECOS revalidation filing (flagship) +2. NPI reactivation (hard NPPES signal) +3. NPPES data update / attestation +4. State license renewal monitoring / filing +5. OIG/SAM exclusion screening + remediation +6. CAQH profile attestation (re-attest ~every 120 days) +7. HIPAA compliance package (universal, not detectable) +8. Credentialing / re-credentialing with payers +9. Taxonomy / enrollment cleanup + +### Suggested rates +| Service | Price | Cadence | Notes | +|---|---|---|---| +| NPPES data update / attestation | **$149** | one-time | low-friction entry product | +| NPI reactivation | **$249** | one-time | hard trigger | +| Medicare PECOS revalidation filing | **$399** | every 5 yrs | flagship, high stakes | +| State license renewal (per license) | **$149/license** | annual/biennial | recurring | +| OIG/SAM exclusion screening | **$99/yr** ($19/mo) | recurring | sticky subscription | +| CAQH attestation/maintenance | **$249/yr** | recurring | high-churn pain | +| HIPAA compliance package | **$799–$1,499** | one-time + annual | biggest ticket | +| Credentialing (per payer) | **$199/payer** | as needed | volume add-on | +| **Provider Compliance Bundle** | **$599–$899/yr** | annual subscription | revalidation watch + exclusion screening + NPPES upkeep | + +Pricing logic: solo/small providers are price-sensitive, but fear of losing +Medicare billing privileges (revalidation, exclusion) supports premium pricing on +those two. Data-update products stay cheap as door-openers. The **annual bundle** +is the goal — mirrors the trucking compliance-bundle model for recurring revenue. + +### Recommendation +Lead with **Medicare revalidation** (real dateable expiry from the free CMS list, +like FCC RMD recert), use **NPI-deactivated** + **stale-NPPES** as secondary +triggers, package into a **$599-899/yr Provider Compliance Bundle**. + +--- + +## 7. Companion Databases — VERIFIED (downloaded & inspected) + +All free, all joinable to NPPES by **NPI**. Counts below are from the live files +pulled on the session date. This is the data that turns "stale record" into a +real, dateable "your X expired" hook. + +### 7.1 CMS Revalidation Due Date List (the flagship) +`revalidation_base.csv` — **~2.9M rows, 2.42M distinct NPIs.** +Columns: Enrollment ID, **National Provider Identifier (NPI)**, First/Last Name, +Organization Name, Enrollment State Code, Enrollment Type, Provider Type Text, +Enrollment Specialty, **Revalidation Due Date**, **Adjusted Due Date**, +Individual Total Reassign To, Receiving Benefits Reassignment. + +**Verified population:** +- **261,878 enrollments have a concrete due date set** (rest are "TBD" = CMS + hasn't scheduled them yet). +- **217,968 are PAST DUE (overdue revalidation)** — these are the hottest leads. +- 43,910 are upcoming (future-dated) — perfect for "due soon" pre-emptive offers. + +This is the direct analog to the FCC RMD recertification date. Sell **Medicare +PECOS revalidation filing ($399)** to the 217,968 overdue + watch service to the +upcoming ones. Join to NPPES to get their address/phone for outreach. + +### 7.2 OIG LEIE (Exclusions) +`UPDATED.csv` — **83,256 excluded providers/entities.** +Columns: LASTNAME, FIRSTNAME, MIDNAME, BUSNAME, GENERAL, SPECIALTY, UPIN, **NPI**, +DOB, ADDRESS, CITY, STATE, ZIP, EXCLTYPE, EXCLDATE, REINDATE, WAIVERDATE, WVRSTATE. + +**Verified:** only **8,608 have a valid joinable NPI** (most exclusions predate +NPI or are entities w/ `0000000000`). Use this two ways: +- As a **screening product** sold to OTHER providers ($99/yr) — "we check you and + your staff against LEIE monthly." +- As a **remediation hook** to the 8,608 excluded-with-NPI (reinstatement help), + though excluded providers are a harder, riskier audience. + +### 7.3 Medicare Opt-Out Affidavits +`OptOut_*.csv` — **56,300 opt-out affidavits.** +Columns: First/Last Name, **npi**, Specialty, **Optout Effective Date**, +**Optout End Date**, address, City, State, Zip, Eligible to Order and Refer, +Last updated. + +**Verified:** **22,379 have an opt-out period ending within 12 months.** Opt-out +auto-renews every 2 years unless cancelled — a real dateable event. Sell +**opt-out renewal / re-enrollment decision support**. + +### 7.4 Order & Referring File +`OrderReferring_*.csv` — **~2.0M rows.** +Columns: **NPI**, LAST_NAME, FIRST_NAME, PARTB, DME, HHA, PMD, HOSPICE (Y/N flags). +Tells us which providers are eligible to order/refer for each program. Use to +**qualify leads** (a provider missing eligibility they should have = enrollment +gap = service opportunity). + +### 7.5 PPEF Public Provider Enrollment +`PPEF_Enrollment_Extract_*.csv` — **~2.98M rows.** +Columns: **NPI**, MULTIPLE_NPI_FLAG, PECOS_ASCT_CNTL_ID, ENRLMT_ID, +PROVIDER_TYPE_CD/DESC, STATE_CD, names, ORG_NAME. This is the authoritative +"who is actively enrolled in Medicare" list. Join against NPPES to find: +- NPPES providers **NOT in PPEF** = not Medicare-enrolled (enrollment opportunity). +- Cross-check enrollment state vs NPPES practice state (mismatch = cleanup). + +### Join architecture +``` +NPPES (10M providers, addr/phone/fax) <- outreach contact + base universe + ⨝ NPI ⨝ +Revalidation Due (217,968 overdue) <- flagship "expired" hook + $399 + ⨝ NPI ⨝ +LEIE (8,608 excluded w/ NPI) <- screening product + urgent flag + ⨝ NPI ⨝ +Opt-Out (22,379 ending <12mo) <- renewal hook + ⨝ NPI ⨝ +PPEF / Order-Referring <- enrollment gaps / lead qualification +``` + +### Headline takeaway +The single best, defensible, dateable hook is **217,968 providers with OVERDUE +Medicare revalidation**, each enrichable with NPPES address/phone/fax for +outreach. That is a larger and harder-deadline audience than the FCC RMD list, +and the $399 revalidation filing is a clean flagship product.