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Hospitals, Physicians, and Clinical Pathology Laboratories Scramble to Prepare for Use of Form 5010 Beginning January 1, 2012

Some medical laboratory organizations risk coming up short on the deadline for implementation of 5010 standards

Less than eight weeks remain before the January 1, 2012, deadline for implementation of Form 5010. Every sector of the healthcare system—from government and private payers to hospitals, physicians, pathologists, and clinical laboratories—is involved in this important healthcare reform.

Many providers and payers are scrambling to meet the Health Insurance Portability and Accountability Act (HIPAA) version 5010 compliance deadline. This is the latest version of standards for the conversion of electronic health records (EHRs).

The Centers for Medicare and Medicaid Services (CMS) continues to maintain a hard line position regarding the deadline, according to an article in Modern Healthcare. “There is no wiggle room,” Denise Buenning, Director of the Administrative Simplification Group in CMS’ Office of E-Health Standards and Services, stated. “We’re holding fast to the date.”

Survey Shows One-Third of Healthcare Industry Not Prepared

That concerns some industry experts and hospital and group practice technology leaders. They believe CMS may need a contingency plan for non-compliant organizations.

Although, the healthcare industry appears to be making progress toward the conversion, a recent survey hints at trouble ahead. In this survey, reported by Healthcare IT News, a significant number of healthcare entities indicated that they are not yet prepared for 5010 implementation in Healthcare IT News. The ICD-10/5010 Readiness Survey was conducted by the Healthcare Information and Management Systems Society (HIMSS).

January 1, 2012, deadline for implementation of Form 5010.

January 1, 2012, deadline for implementation of Form 5010.

“Many healthcare providers are making great strides [toward compliance],” said John Casillas, HIMSS Senior Vice President, Business-Centered Systems, in an HIMSS press release. “While only 38% had a 5010 implementation plan in place in May 2010, by December, that number had jumped to 52%.”

However, at least a third of the survey respondents reported that they either: 1) did not have a plan for testing; or, 2) would not test until fourth quarter 2011. This is why experts predict that a last-minute testing crunch will tax to the limited the resources of payers and claims clearinghouses. “The result could delay or negate receiving payment,” noted Joe Miller, one primary author of the survey and former chair of the HIMSS Medical Banking and Financial Systems Committee.

According to the survey, 66% of respondents planned to upgrade their systems to meet compliance requirements, while 19% planned to use a clearinghouse. The obstacles to testing named by the survey respondents included:

  • payers not ready (67%);
  • competition for resources (53%);
  • vendors not ready (50%)
  • clearinghouses not ready (47%).

The survey also revealed that providers say their number one reason for lack of full attention to 5010 implementation is their the need to devote resources to other projects. An impressive 66% of respondents cited adoption of EHR (electronic health record) systems and the need to meet meaningful use criteria as their top priority.

The HIMSS survey was based on 256 usable survey responses from hospitals and integrated delivery networks (69% of the total respondees), practices and clinics (18%), and other providers, such as long-term care facilities (13%).

5010 is the latest version of healthcare transaction standards, noted HIMSS in its press release. The 5010 platform focuses on the electronic exchange of administrative and financial information between healthcare providers and health plans for patient care services, including eligibility inquiries, service (treatment) authorization and referrals, claims status requests, claims, and remittance advice (claims payment).

5010 Compliance Required to Support Other Mandated Changes

Adherence to the 5010 deadline is critical for several reasons. For one, conversion to 5010 impacts some of the provisions of the Affordable Care Act—including the operating rules—that are predicated on the adoption of the 5010 platform.

The HIMSS press release noted another reason. The federal government has mandated that all U.S. hospitals must use the revised ICD-10 system of coding diagnoses and procedures by October 1, 2013. HIMSS notes that this change represents the biggest overhaul in healthcare in the last 30 years. CMS’ Buenning maintained that further delay for compliance is out of the question, Modern Healthcare reported.

Rady Children’s Hospital (RCH), San Diego, is an example of a provider who may not meet the deadline for 5010 compliance. Albert Oriol, RCH’s Chief Information Officer, told Modern Healthcare that, although RCH has taken the necessary steps toward compliance, it is still unable to submit 5010-compliant claims to all of its business partners.

Take, for instance, Medi-Cal. Medi-Cal is California’s Medicaid program. It is jointly administered by the California Department of Health Care Services (DHCS) and, ironically, CMS. Medi-Cal represents close to 50% of RCH’s business, Oriol said. The hospital has not started 5010 testing with Medi-Cal.

But Oriol doesn’t seem too worried. He expressed confidence that, even if Medi-Cal fails to meet the upcoming 5010 deadline, the state will have a contingency plan to keep operations going, possibly by using a clearinghouse.

Clinical laboratory managers and pathologists should already be involved in testing their lab organizations’ 5010 capabilities with payers serving their region. With the January 1, 2012 deadline fast approaching, this early preparation can be important to insuring that lab claims are processed in a timely and accurate fashion.

—Pamela Scherer McLeod

Related Information:

Another deadline looms: The race is on to comply with Version 5010 rules

Survey: One-third of health organizations not ready for HIPAA 5010

ICD-10/5010 Readiness Survey (PDF)

Anticipating the Disruption from HIPAA 5010 Forms and ICD-10: Essential Action Steps to Maintain Your Lab’s Cash Flow

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