by Lale White
With the Jan. 1, 2012 deadline for transition to the new HIPAA 5010 standard for electronic claims transactions fast approaching, radiology practices should waste no time ensuring that all the development has been completed, and that testing (necessary to avoid billing disruptions, claims rejections, and delays in payment) is in progress for completion by the end of the year.
HIPAA 5010 specifies the electronic exchange requirements between providers and health plans for core electronic transactions, including claims submission, eligibility inquiries, service authorization, referrals, claim status, and remittance advice. The new standards will provide additional functionality and help ensure more efficient claims transactions.
While practices have largely concentrated on the financial incentives for "meaningful use" of certified electronic health records (EHR) and on the upcoming transition to ICD-10 codes, the 5010 implementation is required to facilitate those projects. The 5010 requirements are inextricably linked to Meaningful Use objectives, and are also a critical precursor to transitioning to ICD-10. Missing the deadline is likely to cause billing and reimbursement disruptions, and will affect claims adjudication not only with Medicare, but also with all private payors. Given the critical path nature of 5010, missing the January deadline also bodes ill for a practice’s ability to meet ICD-10 deadlines.
Unfortunately, a number of factors, including the publication late last year of a set of 5010 revisions, coupled with a lack of general industry readiness, have contributed to confusion and delays in transitioning. The net result is that organizations— including ser vice providers, vendors, clearing houses, and payors—now face a highly compressed schedule.
The Centers for Medicare and Medicaid Services (CMS) has mandated Level II compliance by Dec. 31, 2011, meaning "a covered entity has completed end-to-end testing with each of its trading par tners, and is able to operate in production mode with the new versions of the standards." CMS has explicitly stated that it will not extend this deadline.
Even as practices are under pressure to complete testing, they also face an environment in turmoil. Many payors are behind schedule, and will be unable to provide full testing until late in the year, and they do not have a plan for accepting 5010 files into production post testing. Adding to the confusion, many payors state that they are ready, when in fact they are only performing preliminary format testing rather than the full contingent of response files. Our experience at XIFIN has been that even this late in the year, nearly 45 percent of payors contacted are not ready to test.
Some payors who claim to be ready are simply providing format testing, using a tool like Edifecs. While this is an invaluable first step, it does not qualify as adequate demonstration of an ability to operate in a production mode.
In cases where testing is underway, radiology practices and their trading partners should be aware that payors are often understaffed for this effort, and that changes may be required to match the payors’ interpretation of the new formats. Furthermore, a large number of payors cannot return 5010 standard acknowledgements (999, 277CA) or ERA (835), or are seeing delays in processing secondary transactions such as eligibility and claim status. XIFIN’s experience is that an overwhelming majority of payors cannot return all the required acknowledgements or remittance files.
It is inevitable that the general lack of payor readiness will lead to end-of-year bottlenecks, and organizations who wait to test will find themselves at the end of a long line. The best course of action is to contact payors and vendors early, and stay in close communication throughout the testing process.
Be sure that your billing vendor, as your partner and advocate, is staying on top of payor testing and is putting pressure on payors to assure readiness. WEDI, the Workgroup for Electronic Data Interchange, is attempting to track payor and vendor readiness, and can be a good starting point when reviewing testing strategy (www.wedi.org).
Ask your billing vendor to clearly define its role vis-a-vis your organization’s responsibilities. Your vendor should be able to provide a test plan that identifies how testing with your top payors is being prioritized, as well as what the overall process is. MGMA has put together a 5010 checklist (www.mgma.org).
Beyond working with vendors and payors to ensure submittals and acknowledgements function properly under 5010, radiology practices need to identify possible modifications to current workflow and business processes. Organizations should look to take advantage of the improved utilities and efficiencies afforded by 5010, and then be ready to build on this infrastructure with ICD-10.
The 5010 requirements are of immense importance to radiology practices and other healthcare service providers, physicians, and payors, and it is incumbent upon us all to take the necessary steps to ensure a smooth and timely transition.
