Time running out to prep for electronic transaction standards
The race is on to comply with Version 5010 rules
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.