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CloudView blog

Ideas and insights to help health care providers stay informed and profitable in today's challenging health care environment.

We Are Ready for ANSI 5010. Are You?

by Sheila Wiese, VP of Client Development

As you know, we are rapidly approaching another major deadline within our industry. While the transition from ANSI 4010 to ANSI 5010 hasn’t received nearly as much airtime as “Meaningful Use” for example, it is a massive industry change, nonetheless.

How massive? The transition will reset the entire structure underpinning all electronic healthcare transactions (i.e., EDI, ERA, Eligibility, CSI) from the “4010” format to the “5010” format. This shift will improve communications across the entire health care network and becomes the standard on January 1, 2012. The Department of Health and Human Services has mandated the change.

In case you glanced quickly past the date, that shift, you may say that tectonic shift, is less than 90 days away.

As you can imagine, this industry change has enormous implications for athenahealth, athenahealth clients and the entire health care market. Thanks to our cloud-based model, 100% of our clients are already using a 5010 compliant version of our practice management services that we updated at no additional cost.

Here's what's in motion:

  • We started our homework in 2009. First, we built out the changes in our software/connectivity solutions which includes over a thousand updates to our embedded on-demand rules. Our EDI and development teams have worked diligently over the last year to understand the requirements for the new transaction formats as described in hundreds – potentially thousands – of pages of HHS documentation.
  • We kicked off our robust testing plan early this year and we constructed it to ensure we and our clients are prepared for the looming deadline. Our back-office team is actively testing with payers and clearinghouses, as well as looking for new opportunities for rules.
  • We’re also working closely with all of our payers to understand their conversion plans. Since the new formats affect payers and providers, the conversion requires a tremendous coordination effort that extends far beyond our business alone.
  • We are closely monitoring client financial performance (claim submission, claim payment, DAR, denial rate, as well other key metrics) to make sure it is as seamless as possible. If one client receives a payer denial related to 5010, we can write a rule and roll it out to our entire network instantly – so no client has to experience that denial again.
  • We did all this work so our clients don’t need to worry about understanding the new requirements, implementing the changes or testing with payers and clearinghouses.

As we have tackled Meaningful Use—maybe you noticed that we are sharing our data on our Meaningful Use Dashboard—athenahealth is at the forefront of this industry change too.

Also like MU, we are shouldering the burden of something extremely complex and made it nearly seamless for our customers. Yet again, we are living up to our mission of being the most trusted business service for medical groups. To the extent the payers are ready for the 5010 implementation New Year deadline, so are we. Therefore, so are our clients.

But here’s the kicker. While we are ready, several payers may not be ready.  As you can imagine, it’s those payers that present the most risk and we are continuing to work with them. That said, we can submit to payers in whatever format--4010 or 5010--they need so our clients won’t feel any impact.

As we start migrating claims, Eligibility, CSI, ERA, etc. from 4010 to 5010 over the remaining months of this year, there will be some turbulence. Here at athenahealth we are planning educational sessions to review the conversion plan, timeline, customer impacts, etc.

After the transition occurs in 2012, practices will need to closely monitor claim submission, denial rates, DAR, and claim payment to reduce the financial impact to their practice. We’ll be doing this for our practices. Will your vendor do that?

Oh, and by the way, 5010 compliance is just the next step to preparing for the October 2013 cutover to ICD-10 compliance. More on that later.

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