Medicare Announces Another Extension of HIPAA 5010 Enforcement

The Centers for Medicare & Medicaid Services (CMS) announced yesterday that they would again extend the enforcement discretionary period, allowing practices an additional 90 days to become fully compliant with the use of HIPAA 5010 transaction standards. What this means for physicians is that while the implementation date of January 1, 2012, is still in effect, contractors will not reject claims submitted in the 4010 electronic formats until July 1, 2012.

CMA has also surveyed the major payors in California to understand whether they will require claims to be submitted in 5010 format on April 1. While some did require 5010 on January 1, others were allowing for contingencies until April 1. SFMS members will receive a quick reference guide with information on which major payors will require 5010 transactions on April 1 in the March SFMS eNewsletter (due out today).

SFMS/CMA encourages all physicians to continue working with their vendors, clearing houses and billing services to transition to the 5010 format as soon as possible. Offices that transmit directly must ensure their software is updated.

HIPAA Privacy and Security Training Resource

HIPAA mandates that all medical office staff, including physicians, be trained on the HIPAA privacy rules, security policies and procedures. CMA has developed The HIPAA Privacy and Security Rule Training Manual to provide a general training and overview for physicians. The manual contains:

• HIPAA Privacy and Security Rule Quiz
• Customizable checklist detailing the specific privacy and security rule responsibilities of the employee
• Employee certification form

The HIPAA Privacy and Security Rule Training Manual is a joint effort by the California Medical Association (CMA) and PrivaPlan® Associates, Inc.

SFMS/CMA members can access this resource free of charge at resource library.

Another resource for HIPAA compliance is the CMA/PrivaPlan HIPAA Privacy and Security Compliance Toolkit. The toolkit is customized for California law and contains customized forms, policies and procedures to ensure HIPAA compliance.

Ensure a Smooth Transition to 5010

Health care organizations that submit transactions electronically are required to upgrade from Version 4010/4010A to Version 5010 transaction standards. This mandate applies to anyone covered by the Health Insurance Portability and Accountability Act (HIPAA) and carries a January 1, 2012 deadline. To be compliant, organizations must use version 5010 to send and receive claims and all other HIPAA adopted electronic transactions starting January 1, 2012.

CMS Office of E-Health Standards and Services (OESS) has announced that it would exercise its enforcement discretion with respect to any HIPAA covered entity that a complaint is filed against for violation of compliance with Version 5010, and the National Council for Prescription Drug Programs (NCPDP) D.0 and 3.0 standards. The enforcement discretion period is from January 1 to march 31, 2012.

Steps to Ensure a Smooth Transition to 5010

• Have a transition plan in place. This plan should document stapes that will be followed and the dates that milestones will be achieved to comply with 5010 requirements. Make your plan available to payers and other business partners so that testing can be scheduled.

• Communicate with vendors regularly. Providers should identify areas within their practice that depend on vendor support and communicate with their vendors accordingly to ensure their systems will be up-to-date. Hold vendors accountable by discussing business requirements to ensure products are 5010 compliant. Ask vendors about new 5010 features and request trainings to ensure internal staff is comfortable using the updated system. Lastly, talk to vendors about any contract upgrades or costs involved with implementing the new software.

• Reach out to a clearinghouse for assistance. A clearinghouse ensures that claims smoothly transition between practices and payers. When providers submit noncompliant claims, the clearinghouse translates the claims into a compliant format and sends the compliant transaction to payers. The clearinghouse serves as a translator from the 4010/4010A to 5010 format. Even if you normally submit your claims to your business partners directly, a clearinghouse can bridge the gap if you are behind in 5010 implementation, and maintain the submission and processing of your claims while you complete your transition.

• Establish a line of credit. Providers should work with their financial team to establish or increase a line of credit to cover potential cash flow disruptions. A line of credit will help a provider’s practice prepare for potential delays and denials in payer claims reimbursements due to noncompliant 5010 transactions being submitted.

• Take advantage of the free software available to Medicare Fee-for-Service (FFS) providers via Medicare Administrative Contractors (MACs).

If you have not already done so, SFMS encourage its members to begin testing for 5010 to avoid claim submissions in 2012. Non-compliance with 5010 may also lead to difficulties meeting the October 1, 2013 ICD-10 transition deadline. Please visit www.cms.gov/ICD10 for more information and resources about 5010 and ICD-10.

Update on HIPAA 5010 Compliance Deadline

January 1, 2012 marks the compliance deadline for use of the new version of the standard electronic Health Insurance Portability and Accountability (HIPAA) transactions. Version 4010 has been in use since 2003 and the Centers for Medicare and Medicaid Services (CMS) is requiring all HIPAA “covered entities,” which includes physicians who conduct any of the transactions named in HIPAA electronically (i.e., claims or remittance advice), to begin using Version 5010 starting on January 1, 2012.

CMS Announces Enforcement Flexibility

Organized medicine advocated to CMS that overall lack of industry readiness should not compromise physician cash flow following the January 1, 2012 compliance date. For this reason, CMS has indicated they will not levy any enforcement actions for the first three months of 2012 while HIPAA covered entities continue to work towards compliance. What this means is that the HIPAA 5010 compliance date remains January 1, 2012 and all physicians and other HIPAA covered entities should continue to make every effort to comply with the use of the new standards, but that CMS will not take any enforcement action during this period.

Medicare’s Plans

Medicare, as the largest insurer that is required to comply with HIPAA requirements, has indicated that they are continuing to work with those who submit claims directly to them (Submitters). Submitters include clearinghouses, third party billers, and physicians who submit claims directly (without the use of a third party or clearinghouse) to Medicare. Every submitter is required to test with Medicare before claims can be processed using the 5010 format. Medicare remains focused on ensuring all Submitters have tested successfully and that claims processing is not interrupted.

Direct Submitters

If you are a physician who sends claims directly to Medicare (“Submitters”) without the use of a billing service or clearinghouse:

• If you HAVE NOT tested by December 31, 2011: You are required to submit a “transition plan” to your Medicare contractor that details your plans for moving to 5010 and when you think you will be able to test with Medicare. You will have 30 days to do this once you have been contacted by your Medicare contractor.

• No prescribed format for transition plan: It can be sent via letter, email, or fax and can be a brief explanation of your transition plans.   
• Keep evidence plan was submitted: Submitters are strongly encouraged to retain evidence that a plan was sent (i.e., return receipt email, fax transmission confirmation, copy of an email).  
• All submitters must test: Unless submitters have tested with their Medicare contractor, even if you submit compliant 5010 transactions, your claims will be rejected. 

• If you HAVE tested successfully by December 31, 2011: You will be contacted by Medicare and told you have 30 days to move over to use of the 5010 standards. Submitters that have not yet tested with Medicare prior to the compliance date will be contacted and asked to submit the transition plan described above.

Physicians who use a clearinghouse or billing service to submit their claims

Physicians who rely on a billing service or clearinghouse to submit their claims to Medicare ARE NOT required to file a transition plan to Medicare. The entity they use to submit their claims is the Submitter and is the one required to submit a transition plan. These physicians should contact their billing services or clearinghouses to determine their ability to generate the physician’s claims and other transactions using the Version 5010 format.

For more information on 5010, please visit https://www.cms.gov/versions5010andd0/.

Physicians: Mobilize Your Practice and Improve Patient Care Delivery

A study conducted by the Joint Commission reported that miscommunication between caregivers during patient hand-offs plays a role in an estimated 80% of serious preventable adverse events. In a time when medical professionals are exploring ways to improve quality of care, why haven’t we tackled the simplest and most cost effective way to achieve this—improving communication? More than 90% of physicians report using a smart phone, and SFMS is excited to announce a new member benefit that leverages this technology to share patient information throughout the local medical community.

All SFMS resident and practicing physician members enjoy exclusive and free member-only access to DocBookMD, a HIPAA-compliant smartphone app to connect with local physicians and pharmacies. DocBookMD gives you the entire San Francisco physician database on your mobile devices. You can:

• Network with local physicians to develop relationships for referrals
• Find colleagues to consult on medical decisions
• Obtain second opinion from a fellow colleague immediately—getting a text or email back from a doctor who, in some cases, can save a patient’s life

As an added bonus, all new SFMS member registrations between December 13 and December 20 will be entered into a prize draw for a brand new iPad2.

“I find DocBook to be an extremely useful mobile application that allows me to communicate with my colleagues in a secure manner.  In fact, I use it to help colleagues with difficult dermatologic cases that cannot be seen at my office immediately.  I am so glad that the San Francisco Medical Society is able to offer this as a free service for its members.” —Lawrence Cheung, MD, SFMS Member

To download…

Go to the App Store or Android Market to download DocBookMD. All you need is your SFMS ID number to register for free. Need help locating your ID number? Contact Lauren Estrada at lestrada@sfms.org or (415) 561-0850.