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.