MGMA Requests Extension of 5010 Enforcement Delay, Cites Problems Encountered by Physician Practices

Kathy McCoy, MBA February 2nd, 2012

4 Comments Latest by COMMENTOR NAME

According to an article published today on ModernHealthcare.com, Medical Group Management Association (MGMA) President and CEO Susan Turney has called for another delay on 5010 enforcement in a letter to HHS Secretary Kathleen Sebelius. Turney says that “Medical practices throughout the nation are experiencing significant challenges” implementing the mandated Jan. 1 conversion to a new set of electronic claims transaction standards, disrupting medical groups’ cash flow and creating hassles for them.

Turney’s letter lists eight steps HHS needs to take to fix problems that began arising even before the Jan. 1, 2012 deadline HHS set for national compliance with federally mandated use of the ASC X12 Version 5010 standards.

In the letter, Turney says “Should the government not take the necessary steps, many practices face significant delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs or even the prospect of closing their practice.”

In November, anticipating a lack of readiness for the upgrade from the Version 4010 standards then in approved use, HHS announced it would keep the Jan. 1 compliance deadline for the 5010 conversion in place, but would grant a 90-day delay in enforcement of its new rule.

Turney’s letter included these Recommended HHS Action Steps:

1. Instruct the MACs to immediately provide advance payments for physician practices that are struggling to meet the Version 5010 mandate.

2. Extend the enforcement delay until at least June 30, 2012.

3. Permit all covered entities to submit and accept Version 4010 claims until at least June 30, 2012.

4. Permit clearinghouses and health plans to accept and adjudicate Version 5010 claims that do not have all of the required data content, but that have sufficient data content to be successfully adjudicated. HHS should encourage providers and health plans to concentrate strictly on the most critical data content requirements of the electronic claims and other transactions. Medicare should announce that, assuming the claim contains sufficient data to be adjudicated, minor errors in the claim will not trigger an automatic rejection.

5. Instruct the MACs to expeditiously adjudicate all outstanding claims, both electronic and paper.

6. Instruct the MACs to take all appropriate steps to ensure that they can accept and adjudicate Version 5010 claims in batch mode.

7. Instruct the MACs to take all appropriate steps to ensure that call centers are manned appropriately and that they are able to answer incoming provider questions in a timely manner.

8. Closely monitor the readiness level of the industry and take additional steps as needed prior to and after June 30, 2012 to ensure that transactions continue to flow and that physicians are paid.

Turney said in the letter that physician practices have reported numerous problems across various areas of the United States stemming from the transition to Version 5010. The most frequently reported problems have involved:

  • Issues with practice management and/or billing systems that showed no problems during the testing phase with their MAC, but once the practice moved into production phase, found their claims being rejected
  • Issues with secondary payers
  • Rejections due to various address issues (pay-to address being stripped/lost from claims; pay to address can no longer be the same as billing address; no PO Box address)
  • Crosswalk NPI numbers not being recognized
  • “Lost” claims with MACs
  • Old submitter validation information not being transferred
  • Certain “not otherwise specified” claims being denied due to not having a description on the claim (CMS sent a notice of correction of this issue Jan. 27, 2012)
  • Sporadic payment of re-submitted claims (with no explanation for rejections)
  • Protracted call hold times (most typically 1-2 hours) when attempting to contact MACs for further explanation of unpaid and rejected claims (a problem that dates as far back as November 2011)
  • Unsuccessful claims processing (with no reason cited for rejection) despite using a “submitter” that was approved after successful testing with CMS

The letter also stated that, “Many of our members report not having been paid by Medicare and TRICARE since as far back as November 2011 as a result of Version 5010 issues.”

For an update on Kareo’s 5010 readiness, visit our Building Kareo blog and our “5010 the Kareo Way” information page.

4 Comments »

    5010 Enforcement – Are You Ready? Kareo Is! | Kareo said:

    [...] though the MGMA has called today for an extension of the 5010 enforcement delay to June 30, 2012, we recommend that you be ready now since many payers are requiring use of 5010. [...]

    Thursday, February 2, 2012 - 2:59 pm

    J. Timko,MD said:

    What a great time for the insurance companies. They get to reject claims,not pay, collect more interest,screw physicians all because of a stupid form the govt says is needed. Sorry to say this to patients out there but many MDs will end up getting out of insurances,get paid up front and help patients submit to the insurer. Right now we are in a world of Wimpy from Popeye with ins payments”I’ll gladly pay you tuesday for a hamburger today.” Enough is enough.

    Wednesday, February 8, 2012 - 9:06 am

    Kathy McCoy, MBA said:

    Hi, Dr. Timko–we agree, these are extremely challenging times for physicians. It seems like one roadblock after another is being thrown in the way of good patient care, which is what you want to provide. We’ll try to help however we can to remove some of those roadblocks. Thanks for your comment!

    Wednesday, February 8, 2012 - 2:24 pm

    Breaking News: Tavenner Says CMS Will Re-Examine ICD-10 Timeline | Kareo said:

    [...] is particularly interesting following the 5010 enforcement delay, the MGMA’s letter to Tavenner requesting another enforcement delay, and the AMA’s call on Congress to block the ICD-10 [...]

    Tuesday, February 14, 2012 - 9:42 am

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