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ANSI 5010 and Medical Billing: The Agony and the Ecstasy

by Elly Cullen, Senior Manager, Electronic Data Interchange

With all the action in the health IT industry these days, an electronic transaction format conversion has to be one of the least sexy topics out there. But the latest transition has been fraught with danger.

Heading into the last quarter of 2011, the ANSI 5010 conversion had the potential to have a huge negative impact on providers. An unsuccessful conversion would have been disastrous for medical billing: Claims would have been unreadable by payers and payments could have been sent to the wrong locations. In an extreme case, the past decade’s successful migration to electronic transactions could have unraveled, forcing providers back to paper in order to get paid.

Every month, 15 million electronic claim, remittance, eligibility and claim status inquiry transactions flow through athenahealth—and before the ANSI 5010 conversion, we knew the change would impact nearly every one of those medical billing transactions. So, we slated a gradual implementation over a full year.

And yet, despite our best efforts to push early adoption with payers, we had only three payers ready for claim submission in the 5010 format as we headed into the third quarter of 2011. Three payers, accounting for less than 1% of our volume.

Fast forward seven months.

Although the Centers for Medicare and Medicaid Services (CMS) have twice postponed enforcement of these standards (currently scheduled for June 30, 2012), more than 97% of athenahealth’s transactions are now exchanged in ANSI 5010. We’ve since moved on, tackling our 2012 initiatives, including preparations for the massive ICD-10 code update. And those remaining 2.1% of transactions are awaiting payer or intermediary readiness. So, we’ll continue to move these payers and monitor them throughout this year, and probably into 2013.

So, how did the ANSI 5010 conversion go?

It hurt, but it could have been so much worse.

We started Q4 2011 with less than 1% of claims submitted in 5010—by the first week of January, 2012, we had  more than 85% of claims in the new format. This rapid conversion wasn’t without serious impacts to our providers:

  • Without warning, in November, Medicare had unveiled 5010-only enrollment for providers. This meant conversions within each state needed to be completed before any new athenahealth providers could start submitting claims in 5010. If the associated intermediaries could keep up with the testing, and 5010 approvals were done in a timely manner, this could have been manageable. But many couldn’t keep up and some of our new providers suffered as a result. Despite this, we were live with most Medicare carriers by mid-November and fully live in all states before the conversion deadline, minimizing the impact on our providers.
  • With internal communication gaps and the implementation of external tools, many payers couldn’t tell athenahealth how they were interpreting the standards in advance of moving to production. Because of this, athenahealth’s front-end rejection rate, which typically hovers around 1.5%, peaked at 2.4% in January, 2012. While we weren’t thrilled, the only other vendor we’re aware of that shared this metric was happy with their 5% rejection rate. We credit this manageable increase to our production testing process, which mitigated risk by submitting the bulk of claims in 4010 while gradually increasing the 5010 volume with each payer who supported it.
  • Payers and intermediaries who didn’t have careful controls processes in place were, at times, unable to answer basic questions about submitted claims: Who submitted them? How many claims are there? or What is their status? This widespread issue resulted in false compliance warnings, processing delays and reporting errors, and some providers were hit harder than others. Again, through vigilant monitoring and escalation of missing claim research with payers and intermediaries, we were able to resolve these issues. The situation then improved dramatically in February. Some of our providers had significant payment delays, which would have been more extreme had we not detected issues early, analyzed the available data and resubmitted affected claims once we became confident of the best way to move forward.

Here’s why our cloud-based services ease transitions like these:

  • Our cloud-based model allows unparalleled visibility into the financial health of our clients. We’re invested in the whole claim lifecycle—we don’t just pass through a claim and hope it gets to the payer. We confirm receipt, track claims’ progress and ensure remittance is received. And we’ve set up alarms to let us know when  claims don’t get on file as expected. Within a week of a claim submission, if we haven’t seen acknowledgement as expected, we begin escalating issues with the intermediary and payer.
  • We had a testing cycle that was so thorough it elicited ridicule from some trading partners early on. Yet, by the end of the implementation, several payers and clearinghouses were thanking us for our help in their implementation. As an early adopter, we were able to help them detect issues and address major problems before the rest of the pack was ready to start testing. For example, in January alone we encountered nearly 50,000 false rejections from clearinghouses or payers who needed to update their systems and reprocess our clean claims.
  • We allocated the appropriate time, money and people to the change, monitored maniacally, and reacted quickly. Our “war room” processed hundreds of issues with our Development and Rules teams present in the room so that a new requirement or issue could be swiftly implemented as soon as it was defined.

We’re already working on preparations for the big switchover to the ICD-10 code set and tapping into the lessons we learned from 5010 to make it go as smoothly as possible. As always, we want to help providers focus on their patients by serving up the right information at the right time, in the right place.

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