MGMA protests 5010-related payment delays, demands government action

The Medical Group Management Association (MGMA) sent the Centers for Medicare & Medicaid Services (CMS) a letter complaining that physician practices are having trouble getting paid because of the transition to the HIPAA 5010 electronic transaction set, which went into effect on Jan. 1. MGMA demanded that CMS take action to prevent further disruptions to physicians' cash flow.

"Should the government not take the necessary steps, many practices face significantly delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs, or even the prospect of closing their practice," MGMA wrote. "As the transition to Version 5010 is a mandatory step toward ICD-10 implementation, this raises even more concerns, understanding the magnitude of ICD-10 is exponentially greater than Version 5010."

The reference to ICD-10 comes just a week after the American Medical Association sent a letter to House Speaker John Boehner asking him to stop the implementation of the ICD-10 diagnostic code set, scheduled for Oct. 1, 2013.

While MGMA has not called for ICD-10 to be terminated or postponed, it did reiterate its request to CMS to delay enforcement of the 5010 transaction set until June 30, 2011. Previously, CMS said it would not enforce the use of 5010 until the end of March because many providers were unprepared for the Jan. 1 deadline.

MGMA described a number of problems that have resulted in physicians not getting paid by commercial and Medicare carriers. Many practices said they had tested 5010 claims successfully with insurers, but their claims were rejected after they went into production mode. The letter also listed technical issues that resulted in claims denials, such as address problems and non-recognition of NPI numbers.

Government payers, ironically, have been the worst offenders. MGMA said Medicare and TRICARE had not paid many practices since last November.

Besides asking for the deadline extension, MGMA requested that CMS:

  • Instruct Medicare carriers to make "advance payments" to physicians struggling to submit 5010 claims
  • Permit clearinghouses and health plans to accept and adjudicate 5010 claims that do not have all of the required data content, but that have sufficient data content to be successfully adjudicated.
  • Order Medicare carriers to adjudicate claims more quickly, accept claims in batch mode, and answer provider questions in a timely manner.

Meanwhile, in a Health Data Management article, Jackie Griffin, client services director at Gateway EDI, said many providers are experiencing difficulties in getting their claims paid as a result of the 5010 transition. But she counseled patience as the industry works its way through implementation of the new standards.

Here's what Griffin recommended:

  • Know what new elements are required for 5010 claims and provide them. Otherwise, the clearinghouse can't help you.
  • Monitor your rejections both at the EDI and EOB levels so you can address the issues identified in those claims.
  • Network with other practices in your specialty to learn from their experience.
  • Keep in touch with what industry associations are saying about the 5010 transition.

To learn more:
- read the MGMA letter
- read Griffin's article

Editor's note: FierceHealthIT is hosting a breakfast panel discussion on ICD-10 preparedness on Feb. 22 at the HIMSS conference in Las Vegas. Executives from leading healthcare organizations will share what they're doing now to ensure a smooth--and even profitable--transition to ICD-10. For more information and to register, visit the ICD-10 Readiness for Hospital IT Leaders: Lessons Learned from the Trenches website.