Frustrated by the HIPAA 5010 Transition? Join the Club
The transition to the ICD-10 will create significant revenue cycle challenges for all providers across the continuum of care. If the initial transition to HIPAA 5010 transaction standards is any indication, providers may be in for a bumpy ride.
The initial deadline for compliance with the HIPAA 5010 transition standards was January 1, 2012, but due to industry feedback, the Centers for Medicare and Medicaid Services (CMS) extended the compliance enforcement deadline by 90 days, to March 31, 2012. However, the implementation date remained fixed at January 1, 2012.
Numerous providers have recently told us they are having difficulties receiving payment from claims that have been submitted using the new HIPAA 5010 transaction standards. The feedback has ranged from small “hiccup” type problems, to millions of dollars of “locked up” claims.
Common themes for claims issues
During these types of transitions, understanding common themes can be helpful in easing the bumps in the road. Karla VonEschen, a health care managing consultant with CliftonLarsonAllen, has been monitoring the technical issues related to the HIPAA 5010 transition, and identified some potential reasons providers may be experiencing claims issues. These reasons are directly related to new or expanded claims information, such as:
- No Medicare Secondary Payer (MSP) reason code on a primary claim.
- Submitting a claim with a National Drug Code (NDC) and no unit information.
- Billing an unlisted service and no description.
- Claims being submitted with the traditional five digit zip code versus the required nine digit zip code.
- Billing provider has a P.O. Box address instead of a required physical street address.
“If providers are having problems with claims being denied or not getting paid, these five reasons are a good place to start the process of evaluating denials. Providers should also be aware of what data is needed for the 5010 format and closely monitor rejections. This will help identify trends that can quickly be corrected,” says VonEschen.
Internal changes can impact claims processing
In addition to changes for providers, many payers are going through internal changes as well. These can impact the timeliness of claims processing, and may not be related to anything the provider has or hasn’t done in their claims submission process. For example, in a recent blog posted by Jackie Griffin, manager of training and project implementation at Gateway EDI, she points out some key changes payers are going through including:
- File acknowledgement reports. HIPAA 5010 changes the way claims are formatted, and this will also trigger changes to the format of acknowledgement reports payers send back to providers. Payers are taking different approaches to how they are modifying and using these reports, and as a result, rejections have increased. It appears working through these issues on a payer-by-payer basis is time consuming for the clearinghouses, and resulting in extended lags in payments.
- Payer transition to 5010. Payers began transitioning to HIPAA 5010 transaction standards at differing times, and not all of their partners were aware of their transition timelines. In addition, some who had established dates failed to meet those deadlines. The outcome of both scenarios is resulting in delayed payment of claims.
- Interpretation of 5010 standards. HIPAA 5010 creates a new set of standards for coding, but payers and providers may be interpreting these standards differently. Claims will be rejected when payers interpret standards one way, and providers another way. Your clearinghouse can play an important role in helping providers understand how certain payers are interpreting standards, and provide upfront assistance to minimize rejections.
As mentioned above, the ICD-10 transition will have many bumps, and the initial process for converting transaction standards to HIPAA 5010 is proving this true. Any transition can be frustrating, but for health care providers there are few things more frustrating than transitions that disrupt the revenue cycle.
Access to resources and information can help minimize this frustration, and return your revenue cycle to its pre-transition state. If you are looking for information to assist your organization, contact Karla VonEschen or a CLA partner.