Many providers, payers, claims clearinghouses and software vendors continue to work toward HIPAA 5010 compliance even as the Jan. 1, 2012, deadline has passed and the federal government has instituted a brief grace period.
A session at HIMSS12 in Las Vegas will examine how some organizations have made a successful 5010 transition, and how lessons from 5010 can translate to ICD-10 implementation work.
HIPAA 5010 compliance is a patchwork right now, says Eric Mueller, president of WPC Services, the consulting subsidiary of Washington Publishing Co., which publishes HIPAA implementation guides. Many commercial payers, for instance, are ready for 5010 but most state Medicaid agencies are fall behind. Some clearinghouses have done a good job for large clients but not so good for smaller ones.
A core lesson from 5010 is that when things fail, it’s because of inadequate testing, Mueller says. And that will be magnified a thousand times with ICD-10 implementation, he says.
A 5010 example: A physician practice that uses a clearinghouse to submit claims to all its insurers may have successfully tested 5010 with the clearinghouse. But most clearinghouses do not directly connect with all of their clients’ insurers--the transactions move between two or three clearinghouses to reach all payers.
So, the practice will receive notices of successful submission of 5010 claims to its clearinghouse, but then will get back 835 remittance advice transactions from payers that have wrong or missing data elements. There’s a lot of room in that trail of electronic transactions for things to get screwed up, Mueller says. And that’s why it is important for providers to understand how data moves through all parts of the transaction chain and the types of decisions that payers are making on the data--how they are interpreting 5010 requirements. “Organizations that have been successful have really dug into the data to see test files and results of test files,” Mueller says. “Don’t accept blanket ‘we got it’ test responses.”
Things will get much more complicated with ICD-10. Providers get paid under contracted rates based on diagnostic codes, and when the codes change under ICD-10, the reimbursement will change. Unless a provider organization understands not just how it will handle ICD-10, but also how its software vendors, clearinghouses and payers are doing it, there will be problems, Mueller warns. “You have to dig in and own your project.”
Everyone in the chain--providers, vendors, clearinghouses and insurers--will get dinged if things aren’t right, Mueller says. But the non-providers will still be getting paid for their services. “It’s the provider who risks total disruption.”
Consequently, Mueller hopes to give attendees a number of tips that peers have used to be successful when migrating to different transaction sets and codes, and other lessons being learned about addressing ICD-10. The lasting impression he wants to leave: “Proper preparation prevents poor performance.”
The session, “5010 Aftermath: What Worked, What’s Left and ICD-10 Preparation Tips,” is scheduled on Feb. 23 at 9:45 a.m.
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