Revenue Cycle Management Blog | GroupOne Health Source

HIPAA 5010 Transition Problems

Written by Kaitlyn Houseman | March 5, 2012

Many Physicians experience problems during 5010 Transition

On January 1, 2012, all electronically submitted HIPAA covered health insurance claims were supposed to be submitted using the 5010 platform.  Although CMS had previously announced it would not take any enforcement action against any plan or provider who was not 5010 ready until after March 1, 2012, the January 1 deadline for compliance remained in effect.

Perhaps the most consistent reports heard during the transition were that the problems – whatever they were – were someone else’s fault.  Clearinghouses blamed Health Plans (both commercial and government) and Health Plans blamed providers, clearinghouses or practice management software programs.  There were so many fingers being pointed at others over the past two months, it is a wonder there wasn’t a major up-tick in the number patients showing up in ERs with broken fingers!

And when billing companies tried to contact either commercial or government payers to try to resolve 5010 related problems, billing company staff would spend hours on hold or the health plan’s phone simply was not answered. 

In early February, the Healthcare Billing and Management Association (HBMA) provided a summary of major 5010 related problems its members had reported to the Association, to officials with the federal Office of E-Health Standards and Services (OESS).  This information was provided in response to a request from OESS as part of an industry readiness/transition report they were preparing for the Administrator of the Centers for Medicare and Medicaid Services (CMS). 

The report outlined the major problems experienced by billing companies during the transition. 

  1. Call Volume/Getting through to Plans/MACs.  Plans (MACs, Medicaid, Commercial and Blues) are so swamped with calls, billing companies and others are on hold for hours waiting to get a live person who can answer their questions.  Call hold times of one to two hours are not uncommon from the reports we have received. 
  2. Crossover claims are showing up at the wrong place or going to the incorrect provider. Payments sent to the service location and not to provider in the electronic 837.  Payments going to the hospital instead of the provider because of the system confusing the Place of Service with the billing office address.
  3. We have received reports that a billing company will get a 999 file acceptance with no 277CA claim status response or there is a 999 file acceptance but upon follow-up to check status of the claim, the plan says there is “no claim on file.”  Some payers are either not ready to create 277CA or are having delays in transmitting them.
  4. Some MACs appear to have unilaterally and mistakenly "unlinked" some providers from their enrollment database. While the majority of Medicare providers remain linked properly, some companies believe thousands of doctors have been unilaterally “unlinked”.
  5. Segment requirements differing by carrier.  Some carriers require certain segments to be included while other carriers will reject a file if the segment exists.  Entire files being rejected due to an individual claim problem within that file.
  6. New edits being turned on that were not active during the testing phase without any prior notification to billing companies, vendors or providers.   
  7. Conflicts between information on NPI and 855 requiring a re-filing of the 855 which can take several weeks to complete. 
  8. Zip code and P.O. Box issues resulting in claim rejections.  This also is a principle cause of the full file rejection rather than the individual claim with the incorrect zip code or P.O. Box. Insurance companies transposing the numbers in the provider’s zip code causing payments to not get routed correctly.

Both the American Medical Association (AMA) and the Medical Group Management Association (MGMA) called on CMS to further delay the full enforcement of the 5010 standards until technical problems were resolved.  As of the end of February, CMS had not announced any change in the enforcement date beyond the March 31 deadline.

In response to 5010 transition problems, AMA President Peter Carmel, MD had this to say in early February, “One month since the 5010 standard was put to use, physicians are experiencing very alarming problems that have resulted in significant interruptions in claims processing and cash flow.  It's clear that the problems will not be solved overnight. The AMA fully expects that another extension to the 5010 enforcement deadline will be needed to resolve the emerging issues.”

On February 9th, a CMS spokesman said that the initial "growing pains" from the transition have been resolved. CMS data show that “more than 80% of physician claims using the 5010 format are being sent to Medicare contractors successfully, and all Medicare contractors are meeting claims processing requirements.”

Medicare 5010 related problems appear to be isolated to certain contractors and regions of the country and do not appear to be system wide.  It also appears that certain clearinghouses had an easier time managing the 4010 to 5010 transition than others. 

It was virtually impossible to find someone who did not have some type of transition problem but the magnitude of the problems and the time it took to resolve problems varied significantly. 

Both MGMA and the AMA note that none of the problems cited surfaced during the extensive testing their members engaged in prior to moving to 5010.  The problems identified by both the AMA and the MGMA largely tracked with the 5010 transition problems identified by HBMA members and reported to CMS.

HBMA Washington Report – February, 2012

Bill Finerfrock, Pam Jackson, Zhaneta Mansaku, and Hannah Tuke