Moving Federal Health Care Targets Becoming a Way of Life

by Fred Bazzoli


Moving targets are a challenge in skeet shooting; for health care providers, they are becoming a way of life.

Health care organizations are facing a variety of looming federal deadlines, ranging from implementing electronic health records to adopting new transaction standards. These deadlines -- carefully tracked by health care organizations and professional associations such as the College of Healthcare Information Management Executives -- are intended to put pressure on the industry to stay the course.

But recently some federal deadlines have been pushed back in response to evidence that the industry as a whole is not ready to meet them. For example, the Oct. 1, 2013, deadline for use of ICD-10 codes was postponed in February, and most recently, the deadline for enforcing use of ASC X12 Version 5010 and NCPDP Version D.0 was pushed back for a second time, to June 30, 2012.

These reprieves draw sighs of relief from some industry segments, while evoking frustration from others that have invested time, money and staff to meet the original deadline.

In response to announcement of the HIPAA 5010 extension, Stanley Nachimson -- principal of Nachimson Advisors, a Maryland-based IT consultancy -- said that the delay sends a message to the industry that "the deadline isn't really the deadline, which makes planning for the long-term difficult."

The 5010 delay represents a microcosm of the benefits and costs of pushing back deadlines to accommodate industry readiness. These delays, while utilitarian and pragmatic, give the perception that deadlines on other federal initiatives are likely to be moved.

The 5010 Story

One of the provisions of the HIPAA Act of 1996 called for the implementation of standards for electronically conducting health care administrative transactions, such as claims, remittance, eligibility, claims status requests and responses. Current standards, the Accredited Standards Committee X12 Version 4010, have been in use for at least 10 years and lack functionality that the industry needed and will need in the future, especially for reporting ICD-10 codes.

In January 2009, HHS announced a final rule requiring the exclusive use of new 5010 codes by Jan. 1, 2012. Despite the three-year time frame, CMS announced in November 2011 that it would postpone for three months enforcement action against any entity not using the updated standards. Then, on March 15, CMS announced a second 90-day delay in enforcement, through June 30, 2012.

Several industry organizations sought postponement in 5010 enforcement. For example, the Medical Group Management Association contended that the move to 5010 standards resulted in "significant delays in claims payments" for some practices.

In announcing the delay, CMS indicated that progress had been made toward the switch to 5010, noting that 70% of all Part A claims and 90% of all Part B claims were being submitted in the 5010 format to Medicare's fee-for-service program. "At the same time ... there are a number of outstanding issues and challenges impeding full implementation," CMS said.

One concern is that fewer than half of states' Medicaid programs have made the switch to 5010 transactions. As of late March, only 16 state Medicaid agencies had fully converted to 5010 transactions, and until the latest delay was granted, non-compliant states would have had to do a "hard cutover" to the new system, Denise Buenning, director of the administration simplification group for CMS, said on a March 20 podcast, called "Talk-Ten-Tuesday."

On that show, Buenning said CMS will not extend the deadline again for 5010 compliance. CMS expects that 98% of transactions will be in compliance by June 30.

Growing Frustration

The lack of industry-wide readiness for 5010 standards has caused confusion and additional work for health care organizations, which must maintain the ability to work with transactions based on both 4010 and 5010 standards.

Clearinghouses have been serving as intermediaries for the translation work between standard sets, said Laura Goetz, program manager for HIPAA 5010 and ICD-10 for the project management office of Providence Health & Services.

"There have been a lot of tracking issues for claims," Goetz said. As clearinghouses "step up and step down" the transactions between standards, it's not always clear where problems have been introduced in a claim, and clearinghouses often have limited staff to solve problems, as they are being bombarded with a wide range of 4010/5010 problems, she explained.

Successful transitions take time and effort, Anne Tekautz, revenue cycle lead for Hennepin County Medical Center in Minneapolis, said. "With the introduction of the 5010 requirements, there was extensive coordination and information sharing between our facilities, payer and clearinghouses," she said. Tekautz highlighted miscommunication on remittance and eligibility files as examples of problems that her organization has experienced.

The transition for the new format requires testing of a variety of transactions between parties, Tekautz said. Hennepin conducted intensive tests with its clearinghouse in December 2011 and didn't have much of a problem in its 5010 transactions. However, the transition with some of its payers has been complicated because of their lack of 5010 readiness.

From the payer perspective, the lack of a complete transition has caused issues as well, according to Jeffrey Morrison -- program director for Geisinger Health System in Danville, Pa., which operates an integrated delivery system and health plans.

"As a payer, we had very few problems because we planned for dual processing of 4010 and 5010 transactions," he said, adding, "The most difficult transaction for us during on-boarding was the 834 Eligibility transaction, because it's not mandated but we had to be ready to accept it in the 5010 format. We have several trading partners that have no plans to convert that transaction to the 5010 format, so we'll be supporting 4010 834's for quite some time. "

"It is a killer to support both environments," Stephen Stewart, CIO at Henry County Health Center in Mt. Pleasant, Iowa, said. "It makes claim generation twice as demanding and time-consuming. We have had more than ample time to get ready, and the delays are benefitting those who chose inaction and penalizing those who acted responsibly. Payers being non-compliant is a travesty at this point."

Seamless transaction communication depends on readiness of all segments of the health care industry, including providers, payers, clearinghouses, information system vendors, and state and federal agencies. To transition to handling new standards, products must be updated, installed, tested and errors resolved between parties. It's tedious work, and partners don't always cooperate.

"We had to act as the middle man between the clearinghouse and the health plan, which is always a challenge," Christine Hamilton -- IT supervisor of the Revenue Cycle Team for Covenant Health, an integrated delivery system -- said. She added, "The health plan is rejecting claims but doesn't want to discuss it with us. Instead, they tell us to speak to our clearinghouse. The two are not talking to each other, and we are left trying to argue the validity of their interpretation of the new rules. This is very frustrating and very time-consuming."

Impact on Future Deadlines

The 5010 experience raises questions about the validity of future deadlines, many say. Some expressed doubts about adherence to the initial 5010 date, observers noted.

"This is why some providers and vendors didn't start their [5010] projects until very late. They knew it would be delayed," Hamilton said. "Our claims vendor didn't 'staff up' to accommodate the influx of questions, testing and changes that we needed with our early start on the project. It has been a slow process to get them to respond and resolve."

Because ICD-10 will affect more components of health care delivery and requires more change, any doubt about an ICD-10 deadline will complicate the transition, providers said.

"CMS says it's going into discussions about ICD-10 in April, but nobody's confident when they will announce another deadline," Goetz said. "They're losing a lot of credibility; we're not getting a lot of stability going into ICD-10. It's a massive overhaul, and we are proactively planning, but having a difficult time gaining support and moving ICD-10 forward with a variable date from CMS."

"At times, reasonable extensions are good things," Stewart said. "[5010] is clearly, to me not one of those times. If a deadline is too restrictive, it needs to be delayed, but a series of 90-day delays is about like kissing your sister -- not very satisfying and really not accomplishing much."

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