Getting itchy over 5010 deadline
Providers, plans struggle to upgrade billing systems
Hospitals, physicians and payers are all still scrambling to upgrade electronic billing systems and fix glitches to meet an already extended deadline with standards for electronic submission of healthcare claims and other administrative transactions.
In a sternly worded letter last week to HHS Secretary Kathleen Sebelius, Dr. Susan Turney, president and CEO of the MGMAACMPE, said her medical group members have reported problems arising even before the Jan. 1, 2012 deadline HHS set for national compliance with federally mandated use of the ASC X12 Version 5010 standards.
Turney’s organization, formerly known as the Medical Group Management Association, monitored the planned conversion from the Version 4010 standards in four membership surveys and recently set up a Web-based hotline for the reporting of problems. She warned that the transition is giving medical groups fits. “Should the government not take the necessary steps, many practices face significant delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs, or even the prospect of closing their practice,” Turney said in the letter.
In November, HHS, sensing a lack of industry readiness, announced it would delay enforcement for 90 days, though keeping in place the Jan. 1 compliance deadline for the 5010 conver- sion, which stems from the Health Insurance Portability and Accountability Act of 1996.
One of Turney’s eight recommendations called for pushing that enforcement delay even further back, to June 30. Another called on HHS to “closely monitor” industry readiness up to that extended deadline and then take whatever steps were necessary “to ensure that transactions continue to flow and that physicians are paid.”
Turney said problems are being reported with Medicare administrative contractors and commercial plans. Help lines at the MACS have been overwhelmed, with call-wait times of one to two hours, Turney said.
The American Hospital Association also is fielding member complaints, said Don May, vice president of policy, and George Arges, senior director, health data management.
With the CMS contractors, “There have been a few glitches that have caused payment disruptions that have us very concerned,” Arges said.
Problems involve special “method 2” payments for critical-access hospitals and secondarypayer issues, he said. The CMS apparently gave contractors incorrect instructions and then devised a temporary fix that does not comply with the standards, Arges said. “In the meantime, they’re asked to put in this workaround that has to be undone when CMS puts in the correct edit logic, so it’s kind of a double effort.”
May said the AHA sees this conversion as a preview of the way the CMS and the industry will handle the far more difficult, federally mandated conversion by Oct. 1, 2013, to ICD-10 diagnostic codes. “ICD-10 is something we have advocated for a long time, but 5010 is a critical component for making ICD-10 work, so we are watching this,” May said. “The hope is that CMS can get this resolved as quickly as possible.”
Smack in the middle between providers and payers is Miriam Paramore, senior vice president of clinical services, for Emdeon, a claims clearinghouse that helps providers and plans communicate electronically. Emdeon reportedly oversees 75 million transactions a month and monitors their flow on a daily basis. In December, “there was a huge surge of activity to push to the finish line,” Paramore said.
Claims “submitters” to Emdeon, which include hospitals, physicians and dentists, made big strides toward 5010 compliance between December and January, Paramore said. Fewer than one in four providers were submitting claims in the 5010 format in December, she said, but as of last week, that number had jumped to 65%, according to Emdeon’s latest data.
Federal contractors working for Medicare were accepting all claims in 5010 before the Jan. 1 compliance deadline, although there were glitches. Large commercial payers improved, as did state Medicaid programs, which are pulling up the readiness rear.
Still, Paramore is optimistic that almost everyone will be able to achieve 5010 compliance by the end of March. “Everybody is surging toward that finish line,” she said. “We may not be 100% for every provider and payer, but it’s going to be close.” So close, she said, an extension may not be needed. “I don’t want to disagree with MGMA,” she said, but, “we’re in the red zone on the five yard line here and can go ahead and push it over.”
Full compliance will take more time, predicted Sunny Singh, the president and CEO of Edifecs, a developer of business process software and services for payers and providers.
“The industry will continue scrambling for the next two quarters,” Singh said. His company helped 17 health plans and seven state Medicaid programs meet their 5010 deadlines. “They scrambled. Our customers worked inordinately hard, working overtime and weekends. That’s what it took. The entire industry is not in that state.”
Still, Singh said he hopes the CMS does not further extend the 5010 enforcement deadline. “You don’t want to have a trickle effect on upcoming standards. Initiatives such as HIPAA and ICD-10 are good for the industry. But the evidence will not be visible overnight. It will take time.”