Time run­ning out to prep for elec­tronic trans­ac­tion stan­dards

The race is on to com­ply with Ver­sion 5010 rules

Modern Healthcare - - Front Page - Joseph Conn

The Health In­sur­ance Porta­bil­ity and Ac­count­abil­ity Act turned 15 years old in Au­gust, and as ev­i­dence of its last­ing im­pact, providers and pay­ers will be scram­bling over the next four months to meet yet an­other HIPAA com­pli­ance dead­line.

This one is Jan. 1, 2012, ac­cord­ing to an HHS rule, draw­ing on HIPAA au­thor­ity, and it re­quires health­care providers, health plans and claims clear­ing­houses to con­vert from a decade­old set of stan­dards for elec­tronic data in­ter­change to its more modern coun­ter­part.

In geek speak, the in­dus­try must switch from the cur­rent but out­go­ing ASC X12 Ver­sion 4010 fam­ily of stan­dards to the up­dated Ver­sion 5010.

Both ver­sions are prod­ucts of the Ac­cred­ited Stan­dards Com­mit­tee X12, a 32-year-old stan­dards de­vel­op­ment or­ga­ni­za­tion char­tered by the Amer­i­can National Stan­dards In­sti­tute.

Af­ter a very late start, the health­care in­dus­try ap­pears to be mak­ing progress to­ward the con­ver­sion, but top-level ex­perts as well as in­for­ma­tion tech­nol­ogy lead­ers at hos­pi­tals and group prac­tices war­ily sug­gest that the CMS would do well to have a backup plan.

But if providers, plans and claims clear­ing­houses are bank­ing on the CMS to re­treat from the Jan. 1 dead­line, they may find them­selves on the wrong side of the law, ac­cord­ing to Denise Buen­ning, di­rec­tor of the ad­min­is­tra­tive sim­pli­fi­ca­tion group in the CMS’ Of­fice of E-Health Stan­dards and Ser­vices.

“There is no wig­gle room,” Buen­ning says. “If you get one mes­sage across to your read­ers, that’s it. We’re hold­ing fast to the date.”

The CMS is tak­ing a hard line not out of ob­sti­nacy, since it al­ready rolled back the com­pli­ance dead­line once—from the orig­i­nal Oct. 1, 2010 dead­line in its pro­posed rule is­sued in 2009. At stake is not only 5010 com­pli­ance for its own sake, since the con­ver­sion to 5010 is a pre­req­ui­site for the sched­uled Oct. 1, 2013 con­ver­sion to the In­ter­na­tional Clas­si­fi­ca­tion of Dis­eases, 10th Re­vi­sion, or ICD-10, a fam­ily of di­ag­nos­tic and pro­ce­dural codes that is a quan­tum leap in com­plex­ity from the ICD-9 codes now in use. But even ICD-10 doesn’t fully ex­plain the need for 5010, Buen­ning says.

“It im­pacts ICD-10, but it also im­pacts some of the adop­tions com­ing out of the Af­ford­able Care Act, in­clud­ing the op­er­at­ing rules, which are pred­i­cated on the adop­tion of the 5010 plat­form,” she says. So fur­ther de­lay is out of the ques­tion.

“We will en­force,” Buen­ning says. “If we get com­plaints, we will treat them just as we would any other HIPAA trans­ac­tions and code sets com­pli­ance is­sue, be­cause that’s what it is.” (The use of com­mon data stan­dards for elec­tronic health­care trans­ac­tions was man­dated by the broad HIPAA sec­tion on “ad­min­is­tra­tive sim­pli­fi­ca­tion” and the more spe­cific sub­sec­tion on “trans­ac­tions and code sets.”)

But, “the most im­por­tant thing about en­force­ment is not the penalty,” she says, rather, work­ing with of­fend­ers “to get them to com­pli­ance.”

Still, it is al­most a given at this point that the in­dus­try will not be in full com­pli­ance by the 5010 dead­line.

Rady Chil­dren’s Hos­pi­tal in San Diego has done about all it can do, but it still is un­able to sub­mit 5010-com­pli­ant claims to all of its busi­ness part­ners, ac­cord­ing to Chief In­for­ma­tion Of­fi­cer Al­bert Oriol.

“We’re ac­tu­ally in very good shape,” Oriol says. “Of course, right now our big­gest chal­lenge is get­ting our pay­ers to test with us, which we are do­ing with some pay­ers that are ready, but with oth­ers, it’s prov­ing chal­leng­ing.”

One vi­tal miss­ing link is Medi-Cal, the state Med­i­caid pro­gram, which rep­re­sents “close to half of our busi­ness,” he says.

“We haven’t started test­ing with them yet; that’s one of our con­cerns, of course. They re­cently changed their in­ter­me­di­ary, who is run­ning their shop. We hear they’re go­ing to be ready, but I don’t have a clear sense (when), to be hon­est.” But Oriol isn’t pan­icked. “This wouldn’t be the first time that it’s hard for the state to meet a dead­line,” he says. “They do plan con­tin­gen­cies to al­low a con­tin­u­ing of the op­er­a­tions, so, in that re­gard, I am con­fi­dent, what­ever it is that hap­pens, a claim will go through. They’ll fig­ure out a way, through a clear­ing­house.”

Oriol says gear­ing up for 5010 on his end “wasn’t a triv­ial ef­fort. We’ve been work­ing on it for the bet­ter part of the past 18 months or so. We still have a cou­ple of the smaller sys­tems that are not con­nected to our main ven­dor that are not there yet. It’s home health and our con­va­les­cent home, so in the scheme of things, it’s a smaller num­ber of trans­ac­tions. We’re told it will be (done) this month.”

The 4010 and 5010 stan­dards are used to con­fig­ure the ba­sic fi­nan­cial trans­ac­tions of most health­care or­ga­ni­za­tions and health plans—health­care claims and pay­ments. They also carry a few other elec­tronic data mes­sages, in­clud­ing the com­put­er­ized calls and re­sponses that check on the el­i­gi­bil­ity of a pa­tient for health in­sur­ance ben­e­fits as well as the sta­tus of that pa­tient’s claim while it’s be­ing pro­cessed.

Data maven Jim Mechan’s job puts him in a watch­tower po­si­tion over the sta­tus of 5010 com­pli­ance ef­forts na­tion­wide. Mechan is se­nior vice pres­i­dent of elec­tronic data in­ter­change ser­vices for Emdeon, a claims clear­ing­house that Mechan says moves 75 mil­lion elec­tronic health­care trans­ac­tions a month. Emdeon has con­nec­tions with 360,000 health­care providers, 1,400 health plans as well as

For Rady Chil­dren’s Hos­pi­tal in San Diego, Medi-Cal could pose dead­line chal­lenges.

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