Guest Post: 5010 Discretionary Period

This guest post was provided by Brien Keller, Senior Manager of Santa Rosa Consulting, Inc.:

The recently announced 90-Day Period of Enforcement Discretion for the HIPAA transaction standards (ASC X12 Version 5010, NCPDP Telecom D.0, and NCPDP Medicaid Subrogation 3.0) is precisely as it is described…a Period of Enforcement Discretion. It is not a delay in the compliance deadline, nor is it an extension on the continued use of today’s HIPAA transactions standards.

There are three key points to keep in mind:

1. CMS will reject ASC X12 Version 4010A1 claims for payment on January 1, 2012
2. CMS will continue to log and receive complaints of non-compliance
3. CMS will evaluate logged and received complaints, and may approach organizations for detailed compliance plans and/or accounts of good-faith efforts to reach compliance

The spirit of any Period of Enforcement Discretion is that you begin using the new standard in a timely fashion albeit in an imperfect state; the spirit is not to continue using old standards and exploit the Period as a de facto timeline extension. Although submitting an ASC X12 Version 4010A1 claim on January 1, 2012 is technically an “error,” it is not an “error” that CMS (and likely other payers) are expected to allow into their systems for processing into payment. This is evidenced by CMS’s clear statement that it will reject ASC X12 Version 4010A1 claims for payment on January 1, 2012. “Errors” for which the spirit of the Period are intended include those that are sincere and true to the 5010/D.0/3.0 implementation guides and payer companion guides.

Logged complaints with CMS are not positive alternatives. It is almost a certainty that your MAC (and likely other payers) will not take kindly to an organization knowingly delaying use of the new standards until March 31, 2012 and putting them in a position to reject files and log complaints (which is any HIPAA covered entities’ legal obligation). When Periods similar to this one have been introduced by CMS in the past, and when CMS has chosen to approach organizations for evidence of good-faith efforts and/or compliance plans during those Periods, the eye has been sharp and the forgiveness has been rare. Responding to any CMS request or approach will likely consume more time, effort and cost than simply staying the course (although it is now an aggressive course given the time remaining) and achieving timely compliance.

The charge for compliance with the new standards needs to remain January 1, 2012. You’ll want to ensure you are sending the new standards, not the old standards. If you have true and sincere errors within your transactions, you’ll want to understand how your payers will respond…especially if the response is file rejection, payment reduction and/or payment lag. Once you understand the likely reactions, then – and only then – should you consider allowing yourself to remain out of compliance with “errors” after January 1, 2012.

About Santa Rosa Consulting Inc: 

Santa Rosa Consulting is a National provider of information technology and management consulting services to the healthcare industry. Our unique culture, flagship leadership and investment in technology have uniquely positioned us to be the easiest company to do business with and the best company to work for thus Redefining the Approach to Healthcare Consulting. Primary service offerings include:

• Advisory & Consulting Services
• HIPAA X12 5010 and ICD-10
• Vendor Implementation & Integration Services
• MEDITECH Services
• Staffing & Recruiting Services