X12 an early test flight for ICD-10
5010 process offers lessons in communication: experts
Time has run out for the stragglers. After two extensions, the CMS has not added a third period of enforcement abeyance to its rule requiring the use of several new electronic transactions standards.
According to industry observers contacted for this story, there’s no hint that the feds might give the industry one more grace period, the latest of which ended June 30.
The CMS did not respond by deadline to requests for information about enforcement of its rule mandating use of the Accredited Standards Committee’s X12 Version 5010 family of claims standards and the National Council for Prescription Drug Programs’ NCPDP D.0 and 3.0 standards for prescription drug coverage.
“I think that this will be it,” says Sunny Singh, president and CEO of Edifecs, a provider of claims processing software and services to health plans and providers. “I don’t see another extension forthcoming. At the end of the day, a mandate has to have teeth. I think people have gotten enough time to work this out. The industry is in good enough shape.”
Singh and others say the government would do well, however, to apply lessons learned from the 5010 upgrade to upcoming data standards conversions, such as the planned requirement to add health plan identification numbers to the claim stream, and, in what is expected to be a far bigger undertaking, the proposed switch to ICD-10.
Those lessons from 5010 show a need for better communication between all parties involved—government, health plans, healthcare providers, software developers and health IT service providers such as claims clearinghouses.
“CMS and HHS are now in the driver’s seat,” says Dan Rode, vice president for advocacy and policy with the American Health Information Management Association. “If they want a coordinated information system in the U.S., then they’ve got to start putting forward a unified plan of how we’re going to move these systems along. All these pieces need to link together. We now know it will happen, but I think we don’t know how these changes are going to be made.”
It’s not that the government has been impatient in pushing through Version 5010 and other upgrades. Last November, the CMS announced it would keep its Jan. 1, 2012 compliance deadline for them in place, but citing a lack of industry readiness, said it would hold off on enforcement until March 31. By midMarch, however, the CMS pushed back enforcement through the end of last month. Adoption of the 5010 standards is deemed to be a needed precursor to adoption of ICD-10.
The deadline for the upgrade to ICD-10 also has been repeatedly delayed, with the latest proposed rule from HHS in February calling for a shift in the compliance deadline from Oct, 1, 2013, to a year later.
For many group practices, the road to 5010 was more of an obstacle course than a straightaway to improved claims administration, says Robert Tennant, senior policy adviser for the MGMA-ACMPE, formerly known as the Medical Group Management Association.
Some association members, who were surveyed by the MGMA-ACMPE in June, complained that their practice management and billing systems had not been upgraded in a timely manner. Some reported the cost of the 5010 software upgrades ran as high as $16,000 per full-time-equivalent physician.
Others indicated certain claims, which sailed through the testing phase with commercial payers and Medicare contractors, were mysteriously rejected once the groups switched to day-to-day operations, according MGMA testimony before a federal advisory panel on 5010 that met last month.
Resubmitted claims were paid sporadically, with no explanation given for the rejections, the association reported. And perhaps most frustratingly, wait times on calls to some Medicare contractors seeking explanations of claims rejections or other issues soared to between one and six hours.
The American Medical Association, in its own written testimony before the National Committee for Vital and Health Statistics on June 20, also complained of hours-long wait times on calls to claims clearinghouses and payers, and claims payment backlogs of $100,000 to $500,000 for some physician practices.
Maybe the biggest glitch reported was linked to geography, where some state Medicaid programs had difficulties with the 5010 conversion. California’s Medicaid management information system didn’t begin accepting 5010 transactions until the last week of June, according Lisa Gray, a spokeswoman for the California Department of Health Services. It now accepts claims submitted in 5010, but also in the old standard, Version 4010, and will continue to process them using both formats through Dec. 31, 2012, Gray said.
In its membership survey, the MGMA found that 40% of responding practices were still experiencing 5010-related cash-flow problems in mid June.
Asked to locate the kinks in the cash-flow pipeline, 60% cited problems with their claims clearinghouses, 54% with commercial plans,
35% with Medicare, 33% with their billing and practice management systems, and 12% with Medicaid. Most expressed strong confidence their groups were 5010 compliant, but roughly one in 12 still had doubts (See chart).
Part of the problem is that payers are running scared of compliance auditors, despite the six-month enforcement abeyance period the CMS approved, Tennant says.
“The health plans, in most cases, can accept a noncompliant claim,” he says. “It’s coming in in the 5010 format, but maybe it’s missing one piece of data. So the plans reject the claims out of fear of being audited.”
In April, the not-for-profit Workgroup for Electronic Data Interchange launched an online reporting system for 5010 conversion problems and began hosting the first of three webinars, co-sponsored with the CMS, to troubleshoot the conversion.
Better planning and communication would have helped smooth the transition, according to a report to the NCVHS on behalf of WEDI by Laurie Darst, vice chair of program and services for the organization, and a revenue cycle regulatory adviser to the Mayo Clinic
Darst conceded that “looking back, it would have been ideal to offer these webinars and database tools earlier,” adding next time, “there needs to be a central location to log implementation issues, not only for transaction implementations, but also the other future industry implementations,” such as the proposed HIPAA health plan identifier.
The standards development body, ASC X12, can take a measure of blame, Darst says. In February 2010, ASC produced an addendum to its own, previously released 5010 standards, what it called an “errata,” which didn’t receive HHS approval until October 2010. The wait for a final decision on the errata slowed the industry and delayed internal and external system testing, Darst says.
Communications lapses between hospitals and payers “seemed to be consistently a big problem,” the AHIMA’s Rode says.
“After the testing was completed, the payers changed some of the edits in the system, as they normally do, but didn’t think to inform the providers about it, and so even though they passed the testing, they couldn’t get a claim through afterward.” Looking ahead to upcoming changes in exchange standards, improving communications and systems testing should be key federal policy goals, Rode says.
Singh recommends that the CMS promote creation of a single, comprehensive, national platform for end-to-end testing of all affected systems in advance of future implementations of new healthcare transaction standards. “There is a certain amount of customization that you have with each system,” so a national test bed wouldn’t work for all permutations of a new standard, but it could handle maybe 60% of the tasks, he says.
At Good Samaritan Hospital in Vincennes, Ind., the 5010 conversion had no impact on cash flow and was accomplished with only “a few challenges,” says Charles Christian, the 175-bed hospital’s chief information officer.
“The first of the year we were ready to go on our inpatient side,” he says, while its ambulatory-care operations “followed in January and February.” The problems they did encounter were with a claims clearinghouse and the state involving outpatient claims for its seven-county community mental system, but “we figured it out and got it done fairly quickly,” Christian says.
From Christian’s perspective, lessons learned from 5010 will have little bearing on the looming ICD-10 conversion.
“They’re two different things,” he says. “What I relate ICD-10 to is Y2K. It’s about the same level of effort. When we started looking at it, we saw the ICD codes are in everything, and you have to have the capability of doing both (ICD-9 and ICD-10) at the same time. You really need to get your docs on board and get them to partner with you on this. If you have not been working closely with them, you need to.”
Source: MGMA-ACMPE membership survey, conducted June 6-15, based on 205 responses