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Lack of Communication Leading to 5010 Conversion Confusion


The enforcement delay for 5010 may have been a relief to some, but has caused confusion for most.

Everyone is probably familiar with the ANSI 5010-formatting deadline, and we all thought we knew how it was going to impact our lives. Just in case, here is a brief history: The electronic transaction standard was going to be enforced on Jan. 1, 2012. On Nov. 17, 2011 CMS gave everyone a 90-day period of enforcement discretion.

This created more confusion with providers and, I’m sure, carriers. 

For myself, I had to verify several times what they meant by “discretion.” Basically what I learned is that it meant you could convert if you wanted, but didn’t have to until April 1. I think this created more problems than just making a decision to convert or not.

So how did this situation happen? Here’s my perspective. First, the original information was poorly communicated. This is not surprising, as CMS never really does a good job of communicating …anything. In addition, the CMS website is difficult to navigate, let alone find anything “meaningful.” The enforcement decision was too close to the original deadline, which also created more problems.

The individual Medicare Administrative Contractors (MACs) aren’t any better at communicating. Anyway, I relied on my usual source, the AUA’s Practice Manager’s Network, which runs a listserve in which subscribers can participate (ask questions, answer questions, etc.)

No one posting on the listserve really knew what they should do next: Were there problems? Were the carriers having problems? Were the clearinghouses having problems?

I honestly wasn’t sure if we were in a testing phase or not. It took the impetus off testing for our practice, but I went ahead and pulled the trigger and switched all my carriers over to 5010 by the January 1 deadline.

I didn’t notice anything at first and just thought it was just normal “first of the year issues” (deductibles not met). January is usually one of the slowest months of the year for us in any case. About mid-January, I started looking into why clean claims from Medicare that are normally paid at 14 days had not yet paid.

I noticed our Medicare “bucket” for current claims was filling up more than normal. (Your MAC has to pay a clean claim in 28 days but not sooner than 14 days.)

I started worrying at day 21 and tried in vain to find a pattern:
• Some had been paid and others hadn’t. I couldn’t find the difference.
• I had our biller call on some claims that hadn’t paid.
• They were “in process.”
• I wasn’t receiving denials or exclusions, the first two things we normally are alerted to if there’s something wrong with a claim.

Finally, I heard from some other folks on the AUA Practice Manager’s Network who were experiencing the exact same thing we were with Medicare - delays with no patterns, no explanation. Some of them had it worse off than us. Ours were trickling in but some had had all of theirs rejected. Most of the ones I heard from had to use their line of credit since it created such a cash flow problem. We haven’t gone that far yet but if it doesn’t improve in the coming weeks, we will.

This entire time I have yet to hear any announcement from any carrier, clearinghouse, or CMS about the status of the conversion or what could be potential problems. This underscores the real problem in all this, communication.

In the end, I think it was the right thing to do but communication should have been better. And I think they should have announced their decision to wait earlier on; 45 days before go-live is unacceptable. My advice is to diligently watch your claims process. Make sure claims are at least in process, that the carrier has received them and they’re not in never-never land. Call the carrier and find out if you’re not sure.

At least you’ll have an idea of what’s processing and what’s not. Good luck.

Find out more about Derrick Berger and our other Practice Notes bloggers.

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