CMS delays 5010 enforcement, yet again

Once again, the Centers for Medicare & Medicaid Services (CMS) has postponed enforcement of its regulations requiring the use of the 5010 standards in all electronic healthcare transactions. Just two weeks before all healthcare providers and payers could have been penalized if they were not using the 5010 transaction set, CMS announced that it would push off enforcement until June 30.

The original deadline was Jan. 1 of this year, but last November CMS delayed the enforcement until March 31 when it became apparent that much of the industry was not ready to make the transition. Since then, the Medical Group Management Association (MGMA), representing physician practice administrators, has repeatedly begged CMS to add another three-month delay.

In a letter it sent to CMS earlier today, MGMA noted that "the migration to Version 5010 of the Health Insurance Portability and Accountability Act [HIPAA] electronic transactions has resulted in significant delays in claims payment" for some practices. MGMA asked CMS to grant an additional 90 days for its members to make the transition and also requested that the agency consider an additional extension if that is warranted.

CMS, however, predicted in its announcement that there would be 98 percent compliance with the 5010 transaction set by the end of June.

The agency also described the progress made to date: "Health plans, clearinghouses, providers and software vendors have been making steady progress: the Medicare Fee-for-Service (FFS) program is currently reporting successful receipt and processing of over 70 percent of all Part A claims and over 90 percent of all Part B claims in the Version 5010 format. Commercial plans are reporting similar numbers. State Medicaid agencies are showing progress as well, and some have made a full transition to Version 5010."

The latter claim, however, underlines a key problem that MGMA has cited in the past: some state Medicaid agencies still are not ready to handle 5010 claims. How quickly that situation will be resolved is unknown.

The association also has pointed to problems that practices have encountered when they went into production mode on 5010 with certain payers. In many cases, the payers were unable to process the claims, and payments were delayed.

This is the second time in the past several weeks that CMS has responded to physician pressure by postponing the deadline for an important initiative. The last time CMS blinked, it said it would delay the start date for mandatory use of the ICD-10 diagnostic set.

To learn more:
- read this CMS announcement
- see the new MGMA letter


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