Medical Group Management Association (MGMA) research on the transition to the new HIPAA Version 5010 electronic transaction standards indicates a need for the Department of Health and Human Services (HHS) to immediately issue a comprehensive contingency plan permitting health plans to adjudicate claims that may not have all the required data content. MGMA’s research suggests that the critical coordination among many practices and their trading partners has not yet occurred. Practices that do not successfully implement Version 5010 by the Jan. 1, 2012, compliance date face possible disruption in cash flow.
"It is clear that a significant number of medical groups will not have the ability to transmit claims and other electronic transactions using the Version 5010 format by the Jan. 1 deadline,” says Susan Turney, MD, MS, FACP, FACMPE, MGMA president and CEO. "In particular, the study results highlight the fact that external testing with health plans is significantly delayed. It is imperative that HHS take immediate steps to ensure that practice operations are not compromised due to cash flow disruption.”
Key findings of the study include the following:
Practice management system software vendors — Only about three-quarters (76.8%) of study respondents have heard from the practice management system software vendors regarding the transition to 5010, and only 35% of respondents indicate that internal testing has begun. Almost one-quarter (21.7%) of respondents reported that internal testing with their practice management system vendor has not yet been scheduled.
Health plans — Just 5.7% of respondents indicate that all their major health plans have contacted them, and just 35% of respondents report that some of their major health plans have contacted them. Only 15% of those surveyed reported that external testing has started with all of their major health plans, and 15.3% reported that testing had started with some of their major health plans. Twenty-seven percent reported that external testing has not yet been scheduled.
Contingency plans — Physician practices were asked about their contingency plans following the Jan. 1 compliance date. More than one-third (33.3%) expected to establish a line of credit at a local financial institution; 35.6% were planning on setting aside cash reserves to sustain operations, and more than one-half (50.6%) reported that they planned to revert to paper claims in an attempt to avoid cash flow issues.
Current implementation status – Just 4.5% rate their 5010 implementation status as fully complete, 50% rate it as between 26% and 99% complete, and 40% of surveyed practices report their current implementation status as less than one-quarter complete.
“It is unacceptable to expect physician practices to take such drastic action, such as reverting to paper claims, to avoid serious cash flow issues resulting from this mandate,” Turney says. “The shift in the industry to electronic transactions in recent years could amplify the problem. Many health plans have transitioned staff away from handling paper claims, and we are concerned that a sudden, large increase in volume could also result in delayed payments.”
MGMA urges HHS to encourage providers and health plans to concentrate strictly on the most critical data content requirements of the electronic claims and other transactions. If the claim contains the minimum content required for the health plan to successfully adjudicate the claim, HHS should not penalize health plans by requiring them to reject it. Medicare should take the lead and announce that minor errors in the claim will not trigger an automatic rejection. More stringent adherence to the data content requirements can come after the vast majority of covered entities have adopted the version 5010 formats.