The deadline for transitioning electronic transactions to the updated 5010 version of the Health Insurance Portability and Accountability Act (HIPAA) transactions standards is July 1, 2012. The Centers for Medicare & Medicaid Services (CMS) had previously moved back the enforcement date to allow the industry more time to convert to the new format. CMS now believes that a sufficient number of practices have effectively made the transition and physicians will begin seeing rejected claims as of July 1, if they are not submitted in the new format. You will be required to conduct electronic transactions such as claims submissions, eligibility verification, claims status, remittance advice and referral authorizations using the updated transaction standards.

 

If you have not successfully converted your programs to 5010, consider using the free CMS software programs PC-Ace Pro 32 (for Medicare claim submission) and EasyPrint (for Medicare electronic remittances). Both programs are available for download from the Palmetto GBA website, www.palmettogba.com/j1b. Click on EDI in the left menu, then on "Software and Manuals."

 

Commercial payors will also require practices to submit electronic claims in 5010 format on July 1.

 

SFMS/CMA surveyed the major payors in California to determine their claim submission requirements. While some did require 5010 on January 1, others allowed for contingencies.

 

Click here to access our member-only reference guide to help with transitioning to 5010 as well as a list of requirements by payor.

It’s been three years since Congress approved a nearly $30 billion plan to digitize health care records, yet much of the health care industry is still drowning in paper. The Bipartisan Policy Center released a 43-page report detailing the gaps in health IT implementation–the biggest concern being a delay in getting the various systems to be able to talk to one another. The government initiative, passed as part of the 2009 financial stimulus package, gives doctors, hospitals and other providers funding incentives to switch to digital record systems. That effort is also considered one of the key elements to overhauling the country’s health care system. Proponents say that electronic records will reduce medical errors and help cut costs by reducing duplicative tests and care. It can also provide enhanced population data to find out the most effective procedures. Part of that law, known as the HITECH Act, called for health care systems to be able to share patient information. But so far, the new report notes that “the level of electronic health information exchange is very low in the U.S.” The effort has been slowed, the report notes, partially because of federal delays in setting standards for how systems should be able to communicate with one another. The report identified six barriers to successfully implementing the technology around the country and made recommendations in each of those areas. The barriers include privacy and security concerns, a lack of consumer engagement and the number of changes that providers are juggling as a result of the health care law. The report suggest that doctors, hospitals, and other providers might be more inclined to embrace the digital exchange of patient information  if they had a business incentive to do so. The report notes that other causes of delays include a lack of enthusiasm among consumers, who often have misperceptions about how electronic records work and security concerns. Previous research, as the report highlights, shows that “health information exchange has a positive impact on both the cost and quality of care.” Source: Kaiser Health News, January 27, 2012.

The California Department of Health Care Services pushed its enrollment in the electronic health record (EHR) system from December 15 to December 20, 2011, for individual providers. Physicians should know that this will not affect their overall incentive payments. Those who enroll in the program will be eligible for the same total incentive ($63,750) whether they enroll this year, or any year up to 2016. Enrollment in the program for hospitals and groups and clinics began as planned on October 3 and November 15, respectively. Under the American Recovery and Reinvestment Act of 2009 (ARRA, or the Stimulus Act), physicians are eligible for financial incentives for demonstrating “meaningful use” of an EHR system. Medi-Cal providers who meet certain patient volume thresholds will qualify for up to $63,750 paid out over six years, beginning as early as 2011 or as late as 2016. In the first year that a physician is enrolled in the incentive program, he or she can receive up to $21,250 for purchasing, implementing or upgrading an EHR system. Physicians will not have to demonstrate “meaningful use” until their second year in the program. Accessing these incentives will require a two-part enrollment. Physicians must first register with the Centers for Medicare & Medicaid Services at https://ehrincentives.cms.gov. They must then enroll in the Medi-Cal Incentive Program at http://medi-cal.ehr.ca.gov. Physicians qualify for incentives if:

• Medi-Cal patients make up at least 30 percent of their patient volume.
• They are a pediatrician with at least 20 percent Medi-Cal patient volume. (However, pediatricians with 20 to 30 percent Medi-Cal patient volume only qualify for two-thirds of the total incentive.)
• They practice in a federally qualified health center, rural health center or Indian health clinic and at least 30 percent of their patient volume is “needy individuals,” such as Medi-Cal, Healthy Families, sliding scale or uncompensated care.

For more information on the Medi-Cal EHR Incentive Program, see http://medi-cal.ehr.ca.gov.

On November 30, HHS announced intention to delay implementation of Stage 2 of Meaningful Use of electronic health records (EHR) until 2014. Under previous rules, physicians who achieved meaningful use in 2011 would have had to move to the higher Stage 2 standard in 2013. Meaningful use is the set of criteria on which physicians must report in order to receive federal incentive payments for EHR adoption. What is currently published as meaningful use is known as Stage 1. Later stages will include more reporting measures and higher standards. The California Medical Association (CMA) filed comments earlier this year with the Office of the National Coordinator for Health IT asking for just such a delay. CMA believes that many physicians will have a difficult time achieving Stage 1, and the delay will give them more time to adjust their practices to the new electronic environment. According to HHS, these policy changes will be accompanied by greater outreach efforts by HHS that will provide more information to doctors about best practices. In communities across the country, HHS will target outreach, education and training to Medicare-eligible professionals who have registered in the EHR Incentive Program but have not yet met the requirements for meaningful use. Under the Medicare EHR Incentive Program, physicians can receive incentive payments as high as $44,000. Meaningful use is the necessary foundation for all impending payment changes involving patient-centered medical homes, accountable care organizations, bundled payments and value-based purchasing. For more information, click here.

By Amy Berlin, MD

If you are thinking about adopting an EHR in your practice, there is one thing you cannot do enough of: Plan. Here are some (free) resources to get you started.

• The American Academy of Family Physicians Center for HIT (health care information technology) has a host of online tutorials and articles created with the office-based physician in mind. Topics include workflow redesign, EHR vendor selection, and implementation.

• Other AAFP articles of interest include: Practicing Without Paper Charts: One Clinic’s Experience Strategies for Better Patient Flow and Cycle Time How to Select an Electronic Health Record System.

• The California Health Care Foundation publishes thoughtful articles and reports on a wide variety of health care IT issues and strategies. Highlights are: Electronic Medical Records: A Buyer’s Guide for Small Physician Practices Physician Practices: Are Application Service Providers Right for You?, Clinical Documentation: EHR Deployment Techniques, Open-Source EHR Systems for Ambulatory Care: A Market Assessment.

• AMA Practice Management resource center including worksheet 15 questions to ask before signing an EMR or EHR agreement.

• Medical Insurance Exchange of California (MIEC)'s publication on important questions to ask EHR vendors

For more on the HITECH Act

• Dr. David Blumenthal’s article in the February 4, 2010 edition of the New England Journal of Medicine
• The Centers for Medicare and Medicaid Services (CMS) fact sheet on meaningful use
• CMS fact sheet on Medicare Incentive Program
• CMS fact sheet on Medicaid Incentive Program CMS HITECH FAQs (sign up for updates when answers change)
• Office of the National Coordinator for Health Information Technology blog – HealthIT Buzz 
• CalHIPSO – California’s Regional Extension Center
• KLAS publishes independent research on EHR and other HIT vendors. Practicing physicians can obtain selected reports at discounted rates.