Get­ting itchy over 5010 dead­line

Providers, plans strug­gle to up­grade billing sys­tems

Modern Healthcare - - FRONT PAGE - Joseph Conn

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.”

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