by: Ben Penn
Published June 11, 2012
Prevent hiccups in your payments when CMS begins enforcing the HIPAA 5010 standard for all electronic claims July 1 by asking direct questions of your clearinghouse or payers to guarantee your claims will be paid.
Some health plans are accepting claims as 5010-compliant during the Jan. 1 through June 30 discretionary period that may no longer pass muster on July 1, warns Robert Tennant, senior policy advisor for the Medical Group Management Association in Washington, D.C.
The most important step you can take in the last few days before HIPAA 5010 enforcement is to ascertain your claims’ compliance. “You want to talk to your clearinghouse and ask them that question – are the claims that we’re submitting either on the front end from the practice or on the back end from the clearinghouse, fully compliant and therefore will we continue being paid once the discretionary enforcement period is over?” Tennant says.
While the latest CMS 5010 transition statistics indicate that as of May 1, 96.9% of a Part B claims were sent in the HIPAA 5010 format, providers must check to guarantee their claims for all payers are compliant.
Follow these five steps now to determine whether you’re at risk for denied payments because of the July 1 5010 cutover:
- Watch for P.O. boxes included in addresses on claims.While most practices have received word that a physical address for each provider must be included and that a claim with a P.O. box will be rejected, it still causes some confusion, especially if your provider works at multiple addresses.Private health plans may feel significantly more pressure come July 1 to reject such a claim error, Tennant says. Check with your clearinghouse to make sure it has correct physical addresses to send with 5010-compliant claims.
- Direct your clearinghouse to contact your high-volume health plans first. For example, a practice with 30% of its payer mix belonging to United Healthcare would want its clearinghouse to check with United before checking with an obscure local payer, Tennant says.
- Pay extra attention to your daily reports of files being sent and accepted by your insurance company if you don’t use a clearinghouse. That way you can see what percent of claims have been submitted by a payer and what percent have been rejected, says Taylor Williams, director of patient financial services for the Emory Clinic in Atlanta. Continue mining those reports carefully in the first several weeks of July so you can then address the reasons for those denials.
- Prepare for a scenario in which private payers aren’t ready for 5010. You must operate on the assumption that government and commercial payers will no longer accept claims submitted with the 4010 standard on July 1, but that doesn’t preclude a private health plan from continuing to pay 4010 claims, Tennant points out. For instance, a payer may experience problems on the cutover date and be forced togo back to 4010 temporarily, Williams says. For that reason, ensure your clearinghouse is capable of translating claims not only from 4010 to 5010 but also from 5010 back to 4010. “In the event your payer is having serious problems, you don’t want to wait on the payer to fix it because you’re getting penalized,” Williams says.
- Revert to financial contingency plans if you discover unresolved problems.If you are not 100% sure that your claims will be 5010-compliant on July 1, follow the steps you likely took at the end of 2011, such as establishing a line of credit, postponing any capital investment and setting aside a cash reserve to meet payroll and other key expenses, Tennant says (PBN 11/14/11).
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