5010 fact sheet suggests concerns about lingering problems

In the wake of its decision to extend the deadline for enforcing the 5010 transaction set to June 30, the Centers for Medicare & Medicaid Services (CMS) has posted a fact sheet on how providers can accelerate their transition to 5010. Some elements of this fact sheet indicate that CMS expects further challenges in implementing the new transaction set.

For example, providers are urged to "establish or increase a line of credit to cover potential cash flow disruptions," the fact sheet says. "A line of credit will help a provider's practice prepare for potential delays and denials in payer claims reimbursements due to noncompliant Version 5010 transactions being submitted."

When CMS postponed the deadline last week, the agency said Medicare carriers and commercial payers already were processing most 5010 claims successfully; CMS expected 98 percent compliance with the transaction set by June 30. Yet it's still talking about "potential cash flow disruptions" of the same kind that have plagued the transition to 5010 since January.

CMS seems to believe that provider submission of "noncompliant Version 5010 transactions" is the main cause of these payment problems. Yet as the Medical Group Management Association (MGMA) has pointed out, many providers have encountered nonpayment issues after going into production with Medicare, Medicaid, and private payers. If both sides had tested the system prior to starting production, it's hard to see why the fault would rest with providers alone.

CMS' fact sheet recommends a number of other steps that providers should take, including:

  • Creating a 5010 transition plan and share it with payers and other "business partners"-presumably, clearinghouses-so testing can be scheduled
  • Communicating with software vendors regularly to make sure their products are 5010-compliant
  • Reaching out to clearinghouses for assistance during the transition. Even if a provider normally submits claims directly to some payers, CMS recommends that it use a clearinghouse during the transition to reformat 4010 claims until the transition to 5010 is complete.
  • Taking advantage of the free software available to Medicare Fee-for-Service (FFS) providers via Medicare Administrative Contractors (MACs).

These are all sound recommendations that should help providers migrate to 5010. But the fact sheet makes clear that completing the transition to 5010 by June 30 is not a slam dunk.

To learn more:
- read the CMS fact sheet

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