By Mark Martin – Senior Director, EDI Product Management
Healthcare issues are heating up in the United States. Healthcare reform and healthcare stimulus are in the forefront of everyone’s mind. While we debate what “Meaningful Use” is, or should be, I want to take a minute and refocus the discussion to issues that have taken a back seat to the current debate. It’s summertime and that means about six months to go before the first big milestone associated with the regulatory change to the X12 5010 version of EDI transactions. While not a trendy topic today, the 5010 changes are set to take place on January 1, 2012 and between now and then the industry has many milestones to manage through in order to reduce cash flow risks throughout healthcare.
To refresh your memory, the 5010 regulatory changes are designed to address several key “lessons learned” during the regulatory change to ANSI 4010, the current standard. Without boring you with the technical details, in summary the changes eliminate unused data on existing claims, and clarify usage on others. The big win for practices with claims should be a reduction of claim differences between payers making it more consistent to successfully submit claims. Electronic Remittance Advice (ERA) changes also benefit practices by forcing additional standardization for payers reducing the payer specific setups and maintenance. This should make it easier to add new payers and increase the initial success with each new payer. Finally, electronic Eligibility is a big benefactor of the proposed changes. The changes should allow more information to be retrieved, and maybe more importantly, allow better information to be received based on a practices specialty. There has been a ton of work on the eligibility transactions that should make this service much more valuable for all practices.
What is Sage doing today?
Sage continues to push forward with our development efforts and ongoing discussions with our vendors and customers. The end goal for Sage is to provide solutions that will allow our customers to take advantage of the new capabilities while limiting risk as the industry transitions from 4010 to 5010. As January 1, 2010 approaches, the industry transitions from a development phase to Level 1 compliancy. Level 1 refers to the governmental designation where the industry is in an internal testing mode. By January 1, 2011 the industry is to have achieved Level 1 compliancy and transitioned to Level 2 compliancy tasks. Level 2 involves testing with payers and migrating to payers who are ready. On January 1, 2012, all transactions are to be conducted with the 5010 specifications. Sage is on track to deliver tools to our customers facilitating 5010 transactions plus utilities to help our customers manage the expected payer by payer, transaction type by transaction type migration that is likely to occur starting in 2011.
What should you be doing today?
Practices today need to be preparing their internal plan for the migration. Key components of that plan should include a review of your hardware environment, your software environment, your payer mix, and your transaction types.
Hardware and Software environments will be important to ensure access to the 5010 transactions. Key issues to address in this area include;
- Knowing how current your technology is – A key to ensuring maximum flexibility will be ensuring your hardware has enough bandwidth to take advantage of the latest advancements. Also, review your connectivity capabilities. Having an internet connection to your server not only speeds up day-to-day activities, but allows you to use the latest tools giving you the quickest methods to receive critical updates.
- Ensuring that your practice management system is ready – Not all practice management systems will be able to process 5010 transactions. Sage offers a variety of 5010-compliant practice management systems built to suit a variety of practice types.
- It is important to keep track of your payer mix in order to ensure you have open communications with and access to your top payer’s main methods of communication. This may be a newsletter, an email update, or their web pages. You will want to start charting out the 5010 communications from your payers so you stay informed of their expected moves in migrating to 5010.
- Your transaction types are also important. Obviously electronic claims are the key to insuring a stable cash flow during the transition, but don’t forget about the other transactions such as Electronic Remittance and Electronic Eligibility. If you are currently using either of these two transactions to streamline your payments or patient information, be prepared to track separate migration plans with your payers. It is highly likely that some payers will transition each service with different timelines.
Timing of changes within the office is important when controlling cash flow and productivity. Many offices will be adding Electronic Health Record (EHR) capabilities parallel to 5010 changes. Designing a plan where changes are implemented in a controlled fashion will go a long way in assuring a smooth transition.
With many opportunities and changes occurring around the same time, now may be the perfect time to take advantage of outside expertise. Knowledge and Consulting Services from Sage can help review your practice objectives and goals, assess your current clinical and business office operations, and help you build a plan that keeps your practice on the right track to achieving improved outcomes. To learn more about Knowledge and Consulting Services from Sage, complete our Request Information form.
While our industry is focused on how to get and spend healthcare stimulus money don’t forget about the pending 5010 changes. These changes impact most, if not all, of your practice’s revenue. Now is the right time to be building a plan that positions your practice to successfully navigate through these changes. Time you spend this summer may pay off for many summers to come.
Mark Martin
Senior Director, EDI Product Management
