CMS said Thursday that it would apply "enforcement discretion" on 5010 and the related National Council for Prescription Drug Programs (NCPDP) version D.0 for pharmacy claims through midyear to allow more providers, public and commercial payers, software vendors, and transaction clearinghouses to comply with the standards. The code sets represent an update to the Health Insurance Portability Accountability Act (HIPAA) transaction standards that have been in place since 2002, in the form of version 4010A1.
The CMS Office of E-Health Standards and Services (OESS) estimated that the healthcare industry will be sending 98% of claims in 5010 or D.0 format by June 30. Currently, the Medicare fee-for-service program is processing more than 70% of Part A (inpatient) claims and 90% of Part B (physician) claims in 5010. "Commercial plans are reporting similar numbers," CMS said in a press release.
[ It's deja vu all over again as industry works to comply. See Healthcare E-Transaction Change Needs More Time. ]
CMS also said that the Office of E-Health Standards and Services will be providing additional technical assistance with 5010 compliance in the near future. "OESS strongly encourages industry to come together in a collaborative, unified way to identify and resolve all outstanding issues that are impacting full compliance, and looks forward to seeing extensive engagement in the technical assistance initiative to be launched over the next few weeks," the agency statement added.
This is the second time CMS has delayed the original 5010 deadline of Jan. 1. In November, the Medicare agency announced a 90-day grace period after the Medical Group Management Association (MGMA)--now officially known as MGMA-ACPME--asked CMS to develop a contingency plan for 5010 implementation because so many physician practices were worried about disruptions in cash flow if they, their practice management software vendors, or transaction clearinghouses were not ready.
Robert Tennant, senior advisor to MGMA, offered qualified praise for the new delay. "Ninety days is a start, but it may not be the end of the process," Tennant told InformationWeek Healthcare. He said that a lot of MGMA member practices have already experienced cash-flow disruptions. "It's hard to figure out who's to blame when the claims don't get paid," Tennant said.
In a letter to acting CMS administrator Marilyn Tavenner, MGMA asked the Medicare agency to continue to monitor 5010 adoption, and extend the grace period once again if necessary. Englewood, Colo.-based MGMA also requested that CMS "strongly encourage health plans and clearinghouses to provide appropriate and timely feedback to submitters of version 4010 or non-compliant version 5010 claims that identify content errors."
"What we are calling for is for payers to be a little more aggressive in communicating where the problems are" in electronic transactions processes, said Tennant. He urged providers to keep communications open with payers--including Medicare contractors--as well as with their IT vendors, transaction clearinghouses, and other appropriate trading partners.
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