Written by Madeline Hyden, MGMA-ACMPE web content writer/editor

If you transitioned to the HIPAA 5010 transaction standard and encountered few or no problems, congratulations. You're one of the lucky ones. Then again, you might have problems and not even know it yet.

MGMA reported last week that practices across the country have had a different experience, including New York Urological Associates.

“I have $100,000 worth of unpaid claims that I don’t know how to get a hold of,” says Janet Bernstein, MGMA-ACMPE member and practice administrator of the nine-physician urology group.

Bernstein, who transitioned to 5010 in September 2011, did not initially notice problems with her claims.

“We didn’t notice any problems right away because we weren’t getting rejection reports,” she says. “I thought everything was fine and didn’t understand what all the excitement was."

In early December she began receiving rejects on entire batches of Medicare claims. Other batches had partial payment.

“I couldn’t get anyone’s attention,” she says. “I really needed to talk to my clearinghouse, but my only contact was with my practice management system vendor.”

Bernstein eventually got in touch with the PMS vendor’s network director who assigned two staff members to her case. Her December claims were eventually paid in February.

“That ruined the end of my year,” she says. “Claims are usually paid within 14 days and I could have really used those funds by year-end.”

Providers and payers were required by federal mandate to use the HIPAA Version 5010 electronic transactions standards starting Jan. 1. However, the Centers for Medicare & Medicaid Services (CMS) announced last December that it would implement a discretionary enforcement delay until March 31. Version 5010, which replaces version 4010, is an updated standard used in healthcare billing software that can accommodate the more detailed ICD-10 codes, which are scheduled to take effect Oct. 1, 2013. The Association also submitted a letter to the Department of Health and Human Services detailing the problems many practices have encountered with 5010 and urging the CMS to take immediate action to solve them. MGMA encourages members to report their 5010-related problems.

Bernstein says her PMS vendor wrote a program for her that determined which claims had been partially paid and which ones hadn’t, stripped them of the billing control numbers that Medicare would recognize and rebuilt them.

“But I had to email them every day to get it done,” she says.

Bernstein says she is still gets regular denials for typical reasons, such as demographic or secondary payer issues. “When claims that are denied for a whole host of reasons, it's usually a problem with what’s going on between the clearinghouse and the carrier,” she says.

Bernstein says her problems are solely with Medicare. However, since only 25-30 percent of her claims are Medicare, her broader payer mix has prevented widespread financial problems for her practice. “If the commercial [insurers] start having issues, I may be speaking a different tune," she notes.

Other than the headaches the transition has induced in her billing personnel, no one in Bernstein’s practice, in particular her doctors, has been affected by the issues with the transition to 5010. That could change, though.

“To them, this is my problem, not theirs,” she says. “Unless it shows up in their paycheck.”

What has your 5010 experience been like? Is your story similar to the one above? Share it in the comments section below.

Read more about the Association’s stance on 5010.  

5010 action steps for your practice