HIPAA 5010 Checkup: Ten Things to Consider

We are just four months away from CMS' Level 1 compliance date for implementation of the updated X12N transactions to version 5010 for HIPAA.  You've come to see the 5010 doctor.  Run your implementation through my "5010 Checkup" below to see how you're doing:

1. Perform a Gap Analysis between 4010 and 5010 to determine the changes for your organization.  CMS has provided an easy-to-read side-by-side comparison of the differences between 4010 and 5010.  This will identify the detailed list of changes needed for your 5010 implementation.
2. Decide what is in scope for your 5010 project versus ICD-10 project.  The changes in 5010 support the increase in field length to support ICD-10.  How much ICD-10 related tasks do you want to include in your 5010 implementation?  What happens if a Physician sends an ICD-10 code to a Payer before the ICD-10 mandate date of October 2013?
3. Decide the transaction to use for sending/receiving acknowledgements in 997 versus 999.  WEDI has a recommendation that says 999 is a must to acknowledge 5010 transactions and not the 997.  I recommend that everyone follow suit and adopt the 999.
4. Consider the impacts on vendors and internal processes.  Some external and internal systems have a solution architecture that employs the X12N transactions as an interface between systems.  Such as payers that have a partnership where they use the 4010 834 to exchange respective member information or an internal system that turns a paper claim into a 4010 837.  Though these are not mandated to transact in 5010, make a list of what these interfaces are and make a decision if it will remain on 4010 or be upgraded to 5010.  This will make sure you have covered all the bases.
5. Give 837 the highest priority as the first one out the gate.  By far the largest amount of coordination and testing in the industry will involve the 5010 837I and 837P.  Given that some entities still have much to do, I suggest getting the 837 out there first so Providers, Clearinghouses and Payers can start testing sooner.  ICD10Watch poll finds that 60 percent of health org's uncertain about meeting HIPAA 5010 Level 1 deadline.
6. Coordinate with your covered entities to determine when to Test.  Make a list of all the Providers, Clearinghouses, Vendors and Payers in which you transact HIPAA transactions and reach out to determine their readiness for 5010 and when you can start testing with them.
7. For Physician offices, contact your software vendors and determine their readiness for 5010.  Your software vendor is probably deep in getting the software ready for 5010.  Just make sure you confirm that this is the case.
8. Determine how you will read the 277CA.  The 277CA is the claims acknowledgement where you can find out claim numbers and any errors coming from the Payer for claims that you submitted.  The 277CA isn't new, however, CMS Fee-for-Service will be using it for the first time, eliminating their human readable reports.  Make sure you have a means to read this; the solution will probably come through the software solution from your software vendor.
9. Determine if you will support Employer Groups to stay on 834 version 4010 and 820 version 4010.  Or will you support 4010 and 5010 for the 834 and 820?  By the way, Health Care Reform in 2016 will necessitate changes again to these transactions...  Employer Groups are not covered entities and therefore, (though I am not a lawyer) I believe they can choose to stay on 4010.
10. Review X12N Errata's.  In the last two weeks, the X12N transactions have been modified via Errata's.  Most are minor changes, with the biggest one impacting the 835, where it now must send back the Patient Name corresponding to what was sent on the 837.  In the past, Payers may have been sending the Patient Name on record from their Membership application, so this may be a good size change for some. 

CMS also has provided two checklists worth reviewing: Checklist for Level I Testing Activities and Provider Action Checklist for a Smooth Transition.

Remember that the intent of the updates made in X12N version 5010 is to make the transactions better based on what we've collectively learned since we started using 4010 a couple years ago.  Therefore, a majority of the changes are layout and consistency across transactions and the complexity of this implementation isn't as high as when we instituted 4010.  I think this 5010 implementation can be pretty straightforward; the simple secret to success is to be a Task Master and make a list of the tasks that must be completed and track them to make sure they are done.

Most Popular Healthcare Twitter #Hashtags

Twitter is a great place to stay up to speed on Healthcare news and opinions.  This post identifies the most widely used healthcare #hashtags and a definition of their use.  Please send along healthcare #hashtags that you don't see on this list! 

#icd10
#billing - medical billing
#ehealth - electronic health
#ehr - electronic health record
#emr - electronic medical record
#healthcare
#healthit - healthcare information technology
#healthcompanies
#healthdiscount
#healthplan
#hcmktg - healthcare marketing
#hcsm - healthcare social media
#hipaa - hipaa
#hitpol - health information technology policy
#HITsm - Health IT social media
#meaningfuluse
#medicare
#mhealth - mobile health
#onc - the office of the national coordinator for health information technology
#ppaca - patient protection and affordable care act
#physician

The Future Health Insurance Ecosystem

The Patient Protection and Affordable Care Act (PPACA) signed into law this year will change the environment that we know of today where we buy and sell Health Insurance.  In the long-term, the buying and selling of Health Insurance will evolve from a Health Plan centric-model to a Health Insurance Exchange centric-model beyond the implementation of Health Care Reform.  This means that over time Health Insurance Exchanges will be the interface where most people will buy insurance and Health Plans will underwrite the insurance.

I put this diagram together to show the current ecosystem (black lines) and future ecosystem (green lines).

The drivers that will shift the future ecosystem (maybe 20 years from now) from a Health Plan centric-model to a Health Insurance Exchange centric-mode, is due in large part to the following factors:

1.  PPACA puts into law an "Individual Mandate" where every citizen must have Health Insurance.  Therefore, Individuals without the option to purchase affordable health insurance through their Employer will now come through the Exchange to purchase their insurance.  In addition, Members of Congress and Congressional Staff must also elect their insurance through the Exchange.

2.  PPACA creates "Small Business Health Options (SHOP) Exchanges" where small businesses can go to offer Health Insurance products to their employees.  In the Commonwealth of Massachusetts, where an Exchange is already established, the Individual and Small Business functions operate together in one Exchange, called the Health Connector.  Most, if not all, States will probably follow this same model to consolidate both functions into one Exchange for simplification.  Small businesses currently find it confusing to compare and choose health insurance plans and welcome the new SHOP Exchanges.

3.  This next one I call the "White Castle Effect".  White Castle recently said that the Health Reform would be very costly on their business, eating into much of their profit.  Health Reform says that employees must not have to spend more than 9.5 percent of their income on Health Insurance and anything in excess is just not "affordable".  However, due to the income level of the employees at the hamburger chain this percentage would be hard to meet for White Castle to still generate a reasonable profit.  It would be more cost effective for White Castle to take the penalty of not offering insurance than to comply with Health Reform.  We can see that other Employers will follow suit on this approach.  This will drive their employees (and employees of other employers like this) to the Exchange.

4.  "Medical Loss Ratio (MLR)" requires that Health Insurers spend at least 80-85% of premium dollars on medical cost.  This is a huge concern for Health Insurers right now because there are services that go into keeping patients healthly that are not categorized today in the "medical cost" umbrella.  It may be hard to keep in-line with the MLR target, depending on what is classified under medical cost and MLR.  An effect of this is that Insurers have already started to scale back the commissions that it pays to Brokers for bringing Individuals and Employer Groups to buy Insurance.  With lower commissions, Broker may exit the market and the Individuals and Employer Groups will move to the Exchange.

5. This last one is purely my speculation.  As Health Insurance Exchanges settle into the marketplace as a stable working option, Individuals will gravitate to the model.  Employers will see this as a win-win opportunity to ask the government to allow simplification of providing the group health insurance benefit.  Employers may find it easier to provide employees with an allowance to go directly to the Exchange to buy insurance and stay out of the enrollment, contract and health insurance management process.

This opinion assumes that PPACA will go into effect with no major changes.  However, how much of PPACA will be made into reality remains to be seen as things get ironed out.  20 States have filed a complaint with the State of Florida against health reform.  And today, the State of Virgina's lawsuit against the new health care reform law cleared its first legal hurdle to continue further hearings regarding the "constitutional issues" of the new law.  Also, the public-option that allows for a plan created by government and offered through the Exchange is back on the table with the proposal of H.R. 5808.

"Cool" Changes under CMS Fee-for-Service's 5010 Implementation

CMS Fee-for-Service (FFS) is the government agency that is responsible for Claims under Medicare Part A and Part B.  They are currently making some really "cool" changes under the 5010 Project that Providers will be glad to hear about.  Something for Health Plans to consider, as they also implement 5010 by the mandated date of January 1, 2012.

1.  CMS FFS will replace their proprietary claims acknowledgement reports with the widely-used 277CA X12N standard format.  The 277CA is already used by most Health Plans to acknowledge the initial receipt of Claims and to communicate any initial status (such as errors).  This is good for Providers because it means they will receive the same format going forward from Health Plans and CMS FFS which makes claims acknowledgement management easier because it can now follow the same process.

2.  CMS FFS will generate their Claim Numbers up front when the Claim is received.  This is great news for Providers because it means they will be given the assigned Claim Numbers up front so that they can immediately use the number to inquire about the status of their Claim.

3.  CMS FFS will be able to receive paper attachments to electronic Claims.  A Provider can fill out a coversheet and fax the attachments to CMS.  CMS will systematically link the electronic claim to the attachment.  This eases the burden on CMS FFS and Providers because it means no extra time is spent looking for paper or proving that an attachment was mailed or faxed.

4. CMS FFS is going to be ready for 5010 by Jan 1, 2011!  That gives Providers and Secondary Payers ONE year to test with CMS FFS before the mandated compliance date.

How is Medicare Part B Fees calculated?

CMS updated it's fee schedule recently for the reimbursement rates it pay for Part B procedures.  The Factsheet that they put together is very informative.  It describes how CMS determines the reimbursement rate for a claim, in case you ever wanted to know!

Rates are frequently adjusted, usually annually.  With recent regulation, reimbursement rates had gone down which has Providers and Health Insurance Plans concerned.  The update this month increased the reimbursement by 2.2%.

What does Health Care Reform mean to me?

With the health care reform bill newly signed at the beginning of this year, many people are wondering how the federal health care reform bill will impact them.  I've heard stories that when Medicare was instituted that college students were hired to go door-to-door to communicate the message of what the program was all about.  Communication this time around will be equally as important as a lot of people are really confused about the reform.

Very simply, the new health care reform bill means that if you have happy with your insurance through your employer, you can keep it.  However, if don't have the opportunity to buy through an employer or want to purchase independently, you can goto a Health Insurance Exchange to purchase your insurance.  The Health Insurance Exchange will be available starting in 2014 or sooner, depending on the State in which you reside.  The benefit of the reform is that insurance will be more affordable to those where it is out of reach today due to age or health status; everyone is pooled together so the rates can be more affordable for an Individual.  The benefit of the Exchange is that it will provide consumers many product options where it is easy to compare and choose a health plan.  To see how an Exchange might evolve, take a look at healthcare.gov which is the federal version of what a State might offer to compare plans.  The health reform also has an Individual Mandate, where everyone must now carry health insurance or take a penalty; this is a highly debated topic within the reform.

The details of the regulation are still being ironed out.  Also, 20 States have joined the State of Florida to appeal some of the reform.  Therefore, the final landscape will shake out over time.  Some States have already started their paths to meeting the reform and the Exchange requirements.

text4baby - Mobile Health App

Today is a repeat of yesterday where I stumbled upon another very "cool" mobile health app.  This application is text4baby.  Simple tool where expecting and new mothers can sign up to receive weekly text message tips on their cell phone around the health of mother and baby.  Being a recently new mommy of two, I would have loved this application.  Those without this app would probably do what I did... Every week I would confusingly re-calculate how many weeks along I was and hunt through the motherhood book to find the section regarding my number of weeks.  text4baby is a great idea!

(Though I think the concept is cool, I have to be fair and say that I haven't tried it!)

GE Healthcare Morsel - Mobile App

Stumbled upon a "cool" healthly mobile application today.  It came up as an Ad link in my Google Email (gmail).  GE Healthcare has newly created a mobile app called Morsel.  Their tagline is "your daily step toward better health."  The purpose is to suggest small things that everyday people can easily do to improve their health.  For example, today's entry is "Try rice or almond milk instead of regular milk".  It gives the user the ability to say that they tried it, so you can see how many other people have done this; great motivator to try it when you know others are doing it.  It is still in it's infancy so not much functionality yet; the other cool feature is that you can suggest a "morsel".  In the recent past, I had mentioned to someone that I think it's hard to get healthy people to adopt to healthcare mobile technologies, but actually, I think I may be turning the corner on this.  I would use this app!

Prescription Safety

We found out from the doctor that my infant has an ear infection again. She seems to always get them so this is our third trip to the pharmacy in the last couple months. The doctor called in the prescription in the morning and I went to pick it up in the evening after work. My infant and I were there together, I was holding her on my hip because she's not walking yet. When we arrived the line was probably ten people deep, something that I've experienced before at this pharmacy. It was about fifteen minutes until we got to the front of the line for pick-up. I think someone should create a vending machine for frequently prescribed low-risk drugs and leave the personal interaction to the more complicated situations.

At the front of the line, I told the cashier my daughter's name and she couldn't find her prescription so then I had to wait for the ONE Pharmacist on duty. Another half an hour later, we find out that her prescription was flagged earlier by the prior Pharmacist on duty because the dosage prescribed by the doctor was double what is recommended. For someone like me who is curious about healthcare process and systems, this was interesting to me. I had not experienced this type of feedback before. The Pharmacist said it would probably be another half hour while she checks with my daughter's doctor. At this point, it was 45 minutes since we arrived to the pharmacy and my daughter was getting impatient so we left and I would come back later.

When I went back later to pick up the prescription, of course I had so many questions. How did the Pharmacist know it was double the dosage? Did the computer tell her that? I did ask the questions and the answer was, they have a manual process where they check the appropriateness for all prescription for children under one years old. They do have a system that checks the appropriateness of some prescriptions, but this did not fall into that category. The Pharmacist did get ahold of the doctor and confirmed the original dosage was incorrect and modified it. I was so happy that they identified this conflict since it wasn't safe for my baby. I was so happy and the Pharmacist too seemed beaming that she could help.

Bringing this post back to Technology. I was surprised that this wasn't caught by any system either at the Physician's end when writing the prescription or at the Pharmacy. Patient safety is critical and risky for health businesses if prescriptions are not appropriate for the patient. I am extremely grateful that through human review this error was found. However, this is a scenario that I think needs to be more protective to patients by the use of technology. We should be integrating tools like prescription screeners to improve patient safety.

21 Days; 7 Seconds

21 Days = The number of days in which if an activity is repeated it will become adopted by the person.
7 Seconds = The amount of time it takes for someone to form a first impression.

Though I haven't validated these to be the common school of thought, it is what an instructor had told us today.

So how does this relate to healthcare?  Well, I recently blogged about lack of user adoption for healthcare applications delivered on web and mobile technology.  So maybe we can try something here.  Let's get in the face of the users for 21 days to remind them about the benefits of these applications and also incent them to use the product for it's intention for 21 days and see if that helps with adoption.  And let's remember in the design of these applications that we have 7 seconds to catch the users' attention where they will decide if they will buy or fly.  So make sure the entry point to the application is one that quickly wow's the users to stick around.

Healthcare Mobile Technology

I went to a conference recently where one of the sessions discussed Healthcare Mobile Technology.  The panel spoke about their visions and excitement of what Mobile Technology can offer to patients and how their healthcare companies have been involved in this space.  The excitement is that we can involve patients in more around their health management and keep them healthy using a device that is already integrated into their daily life, smart cell phones.  One of these companies is Ubiqi Health which is focusing Mobile Technology for the management of migraines. 

I've personally seen Health Insurers spend Millions on putting tools on the Web for patients.  However, what we have seen is that people are not adopting to the Web and the Return of Investment is not realized.  With that said, I apply this too to Mobile Technology.  I believe that people are not totally adopting to using healthcare applications on the Web and Mobile Phones.  I think we need to spend time to fix adoption before spending too much more money on healthcare tools in these platforms.

A couple of mobile and web 2.0 healthcare sites that I want to point out:
http://ubiqihealth.com/
http://www.healthrageous.com/
http://www.patientslikeme.com/

Also, http://health2con.com/ is a great group for following health 2.0.

Healthcare Human Resources Shortage - Right Around the Corner

With Health Care Reform coming down the pike, it makes me think of the magnitude of work that we in the Healthcare Industry are working through right now and the huge amount of work that awaits us.  In addition to keeping our Health Insurance Plans current by slowly updating some of our internal system to realize some efficiencies that new technology provides, we are also faced with many government mandates.  For example, we are looking at 5010 by 2012, ICD-10 by 2013, Health Care Reform varied dates through 2016 and in Massachusetts we are working through Small Business Rate Regulation.  All these efforts are gigantic and the number of human resources alone to get this all done will be many.  There will be an issue in the next couple of years of being able to obtain and secure people to work on all these initiatives.  In the Healthcare industry, when we hire for Healthcare resources, we require prior experience in Healthcare.  We all have a start in healthcare and for me, I had to buy a car, drive 60 miles one way each day and get underpaid in order to get into Healthcare.  I tell people that it's like when we hire a Janitor, we even prefer the one that has worked in Healthcare before.  Though sarcastic, there is some part of truth to this.  So with all the initatives that we must implement in the next couple of years, we will have a hard time in the Healthcare Industry to retain good Human Resources.  My suggestion to solve this issue is that we need to start to look outside of Healthcare and hire talented skills and pair these people up with workers already in Healthcare that can direct, so that we can increase the volume of workers in the Healthcare workforce.