If you are a healthcare Provider you may not be concerned about HIPAA 5010 as the same should not directly affect your patient-physician relationship. However, HIPAA 5010 implications in the healthcare arena and a Practice could be catastrophic if not implemented correctly. At the very least HIPAA 5010 cover the following areas:  Prerequisite for the implementation of ICD 10  Corrects the outdated transaction standard and enhance administrative data exchanges  Includes four basic kinds of changes; front matter, technical, structural and data content improvements Note: HIPAA 5010 transactions go into effect in January 2012, Healthcare Reform will significantly change those transactions–and add new transactions–within just a few years. Peripheral areas affected by HIPAA 5010 ICD-10 – Many organizations will be focused on the Version 5010 upgrade over ICD-10 given 5010 is required prior to ICD-10. Providers who look only at the short term may find themselves revisiting their 5010 implementation. CORE – Administrative efficiency is the primary goal of the CORE initiative (Committee on Operating Rules and Efficiency, http://www.caqh.org.). In a sense, CORE picks up where 5010 leaves off. Through voluntary rules for payors, clearinghouses and providers around the exchange of eligibility information, CORE vastly improves the usefulness of the 270-271 eligibility transaction between payor and provider. Integrating this real-time transaction with providers practice management/hospital information system has proved to be a significant cost saver for providers. Stimulus-Driven Electronic Health Records (EHRs) and Health Information Exchanges (HIEs) – Immediately following the release of the 5010 and ICD10 final rules, the ARRA allocated an estimated 36 billion for provider adoption of EHRs and support of HIEs. This level of investment is expected to have a huge impact on provider organizations, particularly over the next six years when the incentives are most lucrative. EHRs and HIEs focus on clinical information while 5010 is exclusively administrative data; however, clinical and administrative data should be carefully coordinated to achieve anticipated levels of improved care quality and administrative efficiency. EHR integration with practice management systems can significantly improve the front end of the revenue cycle through enhanced charge capture. EHRs and Version 5010 should become more tightly aligned through implementation of pay–for-performance programs. While Version 5010 and HIEs involve the exchange of different types of transactions, organizations may be best served to develop a single robust infrastructure for handling both. Opportunities vs. Challenges There are many opportunities that Version 5010 and this constellation of healthcare information initiatives offer providers and the broader healthcare industry. These include: 1. Practice Management System Upgrade vs. Replacement There is no dispute that Version 5010 and ICD-10 implementation will require an upgrade for practice management systems. This will be compounded by the potential of many providers implementing, in the same timeframe, an EHR and/or upgrading to a more richly functional EHR system. Providers must consider if this is the opportunity to only upgrade their system or replace their practice management or hospital system. Additional considerations in making this decision include: Level of satisfaction with the current system Effort expected to upgrade the current system for Version 5010 and ICD-10 Level of integration desired between the financial system and the EHR 2. Re-examine Clearinghouse Utilization Providers should take this time to examine their clearinghouse utilization. Version 5010 standardizes the HIPAA transactions by more clearly defining the data location and data meaning. One of the traditional roles of clearinghouses has been to bridge the gap between what a payor requires and what a provider sends and vice versa. To the extent that Version 5010 bridges this gap, providers may find that 5010 offers the opportunity to more easily exchange data directly with payors or at least provider’s largest payors. Also, some providers may choose to increase their reliance on their clearinghouse to neutralize the impact of Version 5010 in the short term. Most, if not all clearinghouses are expected to provide Version 4010 to Version 5010 conversion services allowing providers to stay with their 4010 compliant practice management system for a longer time period. If faced with both a Version 5010 and a later ICD-10 upgrade, a provider may choose to forgo the 5010 upgrade by using clearinghouse conversion services. Some Version 5010 changes enrich the transaction with additional data. For example, payors are required to provide all coordination of benefits data in the 271 transaction response to an eligibility request. This is potentially valuable information that can accelerate the resubmission of a claim. Increasingly, clearinghouses are leveraging this type of data provided in the transactions to deliver value-added services that go well beyond the traditional role of transaction exchange. 3. Revenue Cycle Re-engineering Version 5010, particularly when combined with CORE, offers the provider the opportunity to re-engineer significant components of the revenue cycle. Transactions that once seemed too challenging to implement should be reconsidered—especially due to their potential return on investment. This particularly is the case with the real-time 270-271 eligibility transaction and the 835 electronic remittance advice. 4. Transaction Exchange Infrastructure Version 5010 implementation offers the opportunity to improve and integrate rather than comply and cross-walk. Trading partners must recognize that Version 5010 development will be easier due to previous 4010 experience, but 5010 deployment and testing will involve more trading partners and transaction types. Providers should begin to communicate now with their trading partners, business partners and software vendors; and they should communicate with them often. A provider should consider identifying those trading partners who are willing to beta test and begin testing as early as possible. Enough time should be allowed to test thoroughly in order to address most problems before implementation. As the move from batch to real-time becomes more realistic, real-time adjudication will also be viewed as a clear possibility due to implementation of Version 5010 ~ especially with outpatient claims. With this shift to real-time processing, testing time for Version 5010 is critical. 5. Quality Measure Reporting ARRA set the stage for increased EHR adoption in physician practices due to financial incentive mandates. Also, this will drive automated and widespread reporting of quality care and performance measures. In the future, administrative data will not only be required for claims, but clinical data may be required for quality measures. This creates the potential opportunity for existing claims-based transaction routes to be evaluated for quality measure reporting to payors and to state health departments. In the future, clinical data requirements may be similar to administrative data for paying claims and performance bonuses. This opportunity will be fruitful only if 1) clinical data becomes uniform in definition and representation and 2) clinical information systems can accept and produce the correct clinical data for these measures. Otherwise, significant manual effort will continue to be needed to support quality reporting activities. 6. Process Improvement Opportunities for process improvement derived from the new design of Version 5010 are many and will need detailed examination to ensure their realization. Providers should look for opportunities in pre-admission, admissions and registration processes as well as in the claim payment processes. For example, Version 5010 requires eligibility responses to include all subscriber/dependent data elements that payors require on subsequent transactions such as date of birth (DOB). Today, many payors require
subscriber DOB on the 837 claim, but do not provide it on the eligibility response for the dependent. Some payors require a DOB match for claim processing. The matching of the DOB during the eligibility checking process will allow providers to store the matching information upfront in the process. Currently, lack of this information leads to phone calls, denied claims and appeals. Because this information may now be available in the initial communication with the payor, additional search options including member identification can be leveraged. The improved ability to match a patient to a payor should reduce the number of claims denied because of syntax problems with the name. Another example for process improvement will come from the addition of 45 new “Service Type” codes. This is important in environments where physician and hospital events are covered by different insurers. For example, one carrier may cover physician services and another may cover hospital services. A query to a payor would require a response of both hospital and physician service types if covered. Coordination of Benefits (COB) information will tell providers which payor is primary and which is secondary and facilitates the correct payor to be billed the first time. Other changes such as the definition of “provider,” which will become the Pay-to Address, will enable the direct payments to the correct providers. Changes in the 276/277 Claims Status and Response transaction may help improve adoption of this transaction; therefore, reducing phone calls and staff time with tracking claims. Version 5010 requires multiple claim identifiers be returned when a claim is sent out. This feature of Version 5010 enables the automation of claims status work lists generation and improves claims tracking. Responses will be limited to the claims for which the inquiry is made and a more robust response will be required. I do know that most Providers will consider HIPAA 5010 irrelevant and that all decisions regarding the same may be either delegated or postponed until the last minute. My position and recommendation is that is important to be proactive and to consider how these upcoming changes will affect your bottomline to include your present operations.