First of all I want to mention that there are many many billers who do not understand how the 5010 implementation affects them and are not prepared. We actually talked to one owner of a billing service very recently who thought that 5010 was code for ICD10 and it didn’t really affect him, just the people who did the coding. Let me repeat – your software must be capable of submitting your claims in 5010 format. I know it sounds technical but it’s important. Ask your vendors if you are not sure.

Not only does your software need to be capable of the 5010 format, but the clearing house you use must be capable of using it too. We also have heard that many clearinghouses have told billing services that they do not need to be updated but that they will convert the data to 5010 for them. To these people we just want to warn them that this may not work. We have been told that the billers themselves MUST also be compliant. We are actually curious to see who is correct. But if you are one of those people relying on the clearing house to convert your data for you, you should have a back up plan in case it doesn’t work. OK – enough on being ready for implementation which by the way, enforcement is now delayed 3 months. Let’s get back to what happens to the billing software.

What happens depends greatly on how many versions you are updating. For example, if you haven’t updated in several years and there are multiple versions in between your current version and the one you are updating to, you will experience more issues than someone who updates regularly. If you do regular updates, the issues will be fewer. One issue that you experience when updating is loss of production time. If you are fortunate enough to be able to have the actual conversion done during down time (when the office is closed or after hours) then you are lucky. Most have to do it during office hours and it eats up regular production time. If you are a billing service and you have employees this really can be a huge problem. You will want to have other jobs that your staff can be doing during the upgrade.

Also, you will have to do a little maintenance once the update is installed. Making sure the data converted properly, and that all the correct data is in the correct locations. The new version may require that you input required data into new fields. In any case, this maintenance will take time and usually will delay the billing a little longer. If you are updating multiple versions the data may not convert easily. You may have to have someone convert the data for you. Make sure all of this is taken into consideration before the conversion. You don’t want to have the update installed only to find out you have to come up with a way to convert your data.

Another problem you may encounter is a learning curve with the newer version. Usually software doesn’t change a lot from one version to the next but again it will depend on how many versions you are going up. One version to the next may not have that many changes, but going up multiple versions can result in a lot of changes. Sometimes even just one update can result in enough differences that it is like learning a new software. This issue can be big if you have multiple employees and you have to teach them the new changes as well.

New upgrades may also mess with your clearing house. If you use an outside clearinghouse, or one not directly connected with your software you may have to contact them to have changes made on their end as well. If you try to just submit claims using the old format but created on the new system they are not compatible with the clearinghouse any longer. They may need to schedule an installation so you should contact them prior to your upgrade to find out. You don’t want to wait for the upgrade and then find out they are booking installations three weeks out.

Many times people don’t take all things into consideration when preparing for an upgrade and they are broadsided by all of the issues that come along. If you think things out ahead and do your homework, you can eliminate some of the stress that comes with the conversion. No conversion is ever stress free (or problem free) but preparing yourself as much as possible is the best way to reduce the issues.

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If you don’t know if you are 5010 compliant don’t be embarrassed. Find out. There are basically two things you need to check:

1. Is your practice management software compliant? If you aren’t sure you need to find out. First of all, when did you purchase your practice management software or when did you last update the software? If the answer is four or five years ago I can tell you it’s probably No, you are not compliant. If you do regular updates/upgrades and you’ve done one in the past year, it probably is compliant. If you don’t know or just want to be sure, contact the practice management software company or the reseller you purchased if from and ask. Most software companies have websites and they post the 5010 information right on the website. Visit the website to see if your version is compliant.

If your software is not 5010 compliant you will need to update it as soon as possible. Most companies are backlogged right now because many providers and billing services have put it off and are now scrambling to get updated and compliant.

2. The second thing you need to check is your clearinghouse (if you use one). You need to verify that they are 5010 compliant. Again, most have websites that have the information posted. If it is not clearly posted or you cannot tell by the information on the website give them a call and ask them. They can advise you if they are or are not compliant and if they are not, they can advise you when they expect to be.

We use Office Ally for most of our electronic claims and they are not fully compliant (as of the date we are writing this). But they are on track to be compliant before January 1st. The only problem that we’ve run into is that as of 10/1/2011 Medicare will not allow any providers (or billing services) to enroll for EDI thru Office Ally since they are not compliant. So if you are using Office Ally or wish to use Office Ally, you cannot submit any EDI paperwork for Medicare until they are fully compliant.

If you use another method to submit claims electronically (other than a clearing house) then you need to make sure that the method you are using is compliant. Some people have software that allows them to submit claims direct (without going thru a clearing house). Again if you update the software regularly you are probably ok. But you should check with the company that you get the software from to make sure.

There are other things that also are involved with being 5010 compliant such as billing addresses can no longer be PO Boxes and a few others. Another issue is going to be nine digit zip codes on service addresses and facility addresses. Without the appropriate 9 digit zip code the claims will not go thru. But the biggest things are your practice management system and your method of submitting the claims (clearing house or direct). If you have any other issues that you are unsure of, ask. You can always post a question on our forum (free) at www.medicalbillinglive.com/members. The only dumb question is the one that goes unasked.

Well there are just about 70 days left before the full 5010 Implementation. Are you ready? Do you at least know what 5010 is and what you need to do? If you don’t, you are not alone. There still seems to be much confusion out there about what 5010 is and what needs to be done. The problem is that not knowing what 5010 is and how it can affect you and your office can cause an abrupt stop in insurance payments after January 1st so it’s important that you know if it is going to affect you and what you need to do.

5010 is part of HIPAA and is an updated set of ANSI X12 Standards implemented by the US Department of Health and Human Services. It is for electronic exchanges of health related transactions between insurance carriers and provider and/or vendors such as billing services and clearinghouses. So if you are submitting any insurance claims electronically then you will be affected.

If you utilize a clearinghouse to submit your claims then the clearinghouse should be at the very least testing for 5010 compliance. You should be receiving notices from them stating that they are testing, or that they’ve completed testing. If you do not recall getting any notifications you should be looking on their website for 5010 information or contacting them if you cannot find anything.

If you create electronic claim batches then your practice management system must also be 5010 compliant as well. Again, if you are unsure if your software is compliant you should contact your software vendor to find out. If you have not updated your software for years then you can be pretty sure it is not going to be 5010 compliant. You do not want to wait much longer to find out. Not being compliant can affect your receivables (or your provider’s receivables). If you are a billing service you cannot afford to be non compliant.

Waiting to see if the Implementation date of January 1st really takes effect is not a good idea. You are taking a big chance. The Implementation will happen whether they extend the deadline or not so you really should become compliant as soon as possible. Not being compliant may result in a serious disruption of cash flow.

Since January 1st falls on a Sunday the compliance date is actually December 30th for Medicare claims. Any Medicare claims received after 4:00 pm on Friday December 30th that are not Version 5010 will be rejected. Testing is required before claims can be submitted and that testing must be completed by this date. If you submit claims directly to Medicare then you will need to test with Medicare. If you use a clearinghouse, you need to make sure that your software is creating the electronic batches in the Version 5010 and that the clearinghouse has completed testing.

Knowledge is the key. You may not understand all of the details of the Version 5010 and the changes, but you need to know how it affects you. Is your practice management system compliant? Is your clearinghouse compliant? A little research goes a long way. Don’t wait to look into this. There isn’t much time remaining.

But then there are the paper claims – claims for workers comp injuries or no fault (auto) cases or personal injury accidents and even some obscure insurance carriers. Claims are filed on paper and no acknowledgment is received. You wait for payment or some explanation of what they are doing with the claim, but none comes. You try to call but getting someone on the phone is impossible. They aren’t like the larger insurance carriers with automated systems or better yet online claim look-up tools. At best you get a voice mail but if your experiences are anything like ours the messages go unanswered.

So what are our options? Keep submitting the claims into a black abyss costing more time and postage? Continue leaving messages on voice mail that appear to not be manned? Unfortunately there is no magic trick to handling this problem but we have come up with a system that helps to resolve some of these evasive claims.

We’ve developed a form that we use when we have a claim that we’ve submitted twice, haven’t gotten a response and can’t reach anyone by phone. It’s a very simple form. We use our letterhead with our address, phone and fax numbers. We write a brief note at the top stating that attached is a claim or claims that we have previously submitted at least twice with no response from the insurance carrier. Would they please let us know the status of this claim.

We then write in on lines we have labeled the current date, the provider’s name, the dates of service. We then have three check boxes for the insurance carrier to respond with the appropriate response labeled paid with a place for date paid and check number, denied and reason for denial, and not on file. Next we leave a line for the date we are submitting our request. We then leave three check boxes for the insurance carrier to check the appropriate response. We then request this form be faxed back to 315-865-6359 and the person requesting the information signs the form.

We have been amazed at how well this has been working for us. Some insurance carriers mail them back and some fax back and some ignore them too but we are getting responses to most and they come back quickly.

This would be a great time for marketers to contact medical providers offering to come in and explain how 5010 will likely affect their offices. We need to learn to take advantage of opportunities that situations like the 5010 implementation involve. The fact that many offices are not prepared for this change and may not have compliant software will be a huge problem.

If I were marketing now to medical practices, I would send a well designed sales letter offering to come into the office to see if they are up to date. You could offer to bring in lunch for the office staff to make it more tempting to the doctor. I would include with the letter a post card that says something like “Save this information in case your claims stopped getting paid in January! We can help!” If the provider doesn’t take you up on your offer to come in and talk to them about the changes the 5010 implementation will bring they may save the post card just in case. Come January and their claims stop getting paid they may look for that post card and call you frantically.

Strange…..All I had asked was for an explanation of the denial. Told her I didn’t understand it.

So the Tier 2 representative comes on and pulls up the claim and says [QUOTE] “Oh, that’s an RAC audited claim, they are randomly auditing claims and reprocessing them for no apparent reason. You are going to have to request a redetermination because that denial makes absolutely no sense.”

Hmmmm…..Again, strange…………

Seriously?? I have to request a redetermination because Medicare decided to randomly audit, reprocess and deny a claim for no apparent reason and with no explainable reason??

OK…so now I could go off into a long political rant about how the government has just found another way to ‘cut costs’. I mean seriously, consider this:
• It took me a little research to even figure out what they did
• I had to dig back and find the original eob,
• figure out that the claim was reprocessed without any action on my end,
• there were multiple services on the claim so I had to sift thru to find the denied one,
• Read the denial codes to determine that it really didn’t make sense
• Make a phone call to ask
• Find the redetermination request form on their website (the correct one since I was doing an overpayment redetermination, not a regular redetermination
• Complete the redetermination request form
• Attach proof to support my claim (proof that I’m not crazy but they are!)
• Mail it
• Wait to watch for reprocessing

How many providers will never even know they had money taken away?? How many providers have staff that will go thru this trouble?? And how much did they have to pay their staff (hourly wage for time involved in taking care of this)?? More than Medicare actually took back? In some cases yes. So actually Medicare will make quite a bit of money on these RAC Audits!

I’m now stepping down off my soap box and getting back to work.

Michele Redmond
Vice President
Solutions Medical Billing Inc
www.solutions-medical-billing.com
www.medicalbillinglive.com

Summer’s over. Here in upstate NY we had a nice hot summer. Michele’s three girls (15,13, & 6 years old) came to work with her often and spent the summer riding around our large lawn on a newly acquired golf cart. We tried to convince them to learn to help with the medical billing but they only wanted to ride the golf cart.

The two older girls, Mackenzie and Mackayla, dominated the cart and Rebecca rode. Late in August when the two older ones had lost the thrill of driving the cart and were staying home more often, I convinced Rebecca to try driving. She had experienced a couple close calls with her older sisters and was afraid to try but it didn’t take long before she was begging everyone to take a ride with her. She’s been driving her mother and me to our upper office whenever we need to run up there every since.

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I understand why some are concerned about this. EMR companies are using any angle they can to make their product stand out above the others. Some are including billing software and telling the providers that their EMR software “does the billing too.” They also push the fact that the EMR and billing are “linked” to each other. They tell their prospects that they can save money by not hiring a billing service to take care of the billing but anyone who has done billing before knows this is just not true.

Personally I see EMR as a totally separate entity from the billing. Having billing software does not mean it is smarter for a provider to keep the billing in house. In fact, most providers who outsource their billing already have software capable of billing. The issue for most providers who choose to outsource is that they don’t have anyone in the office who can handle the billing, the claims tracking, the phone calls, the clearinghouse and electronic submissions and they recognize that the experience that they get from outsourcing their billing to a service is crucial to running their office efficiently. Many realize that they actually save money by outsourcing. Some have difficulty hiring, training and keeping a knowledgeable person in that position in their office. Very few decide to outsource strictly because they don’t have billing software. [Side note: There are many offices who do the billing in house very effectively. I’m not saying that all office would be better off outsourcing. I’m saying that EMR and having a billing software won’t change a practice from one who should outsource to one who doesn’t need to.]

Bottom line, no matter how good your billing software is, it is only as good as the person using it. A provider’s income relies on the billing. It is crucial that they have someone that understands billing and knows what they are doing. If they don’t they will lose money, no matter how good their software is and whether or not it’s tied in to their EMR.

I believe that the EMR companies will use whatever means they can to sell their product. I’m not saying that some of them don’t have a good billing software that does tie into their EMR software, and that it wouldn’t benefit some providers. It’s just that unfortunately some providers are thinking that with this new software suddenly their billing is going to become much better by just using it and they will no longer need to pay someone (whether in house or outsource) to do the billing for them. But (again in my opinion) the providers that do believe this and buy into the software only to dump their billing service have other issues anyway.

I don’t think that the EMR mandate is going to affect medical billing services all that much. Sure a few of us will lose an account or two, but they are accounts that would have been lost for some reason or another eventually anyway. Anyone who knows anything about billing knows that there is way more involved than just data entry and that a provider has a lot to lose by not having someone experienced in charge. There are definitely a lot of providers out there who understand this and can benefit greatly from outsourcing to keep this industry thriving for a long time.