X12 an early test flight for ICD-10

5010 process of­fers lessons in com­mu­ni­ca­tion: ex­perts

Modern Healthcare - - FRONT PAGE - Joseph Conn

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

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