5010 fiasco: MGMA calls on HHS to act decisively on HIPAA 5010 payment delays

WASHINGTON – Any lingering illusions that the transition to the HIPAA 5010 standard would present only minor glitches have come crashing down. In late January, the Medical Group Management Association sent an urgent plea to the U.S. Department of Health and Human Services, asking the agency to take immediate action to alleviate a host of claims problems and payment delays.

“Should the government not take the necessary steps, many practices face significantly delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs or even the prospect of closing their practice,” wrote MGMA President and CEO Susan Turney, MD, in a letter to HHS Secretary Kathleen Sebelius.

According to MGMA, many of its members have reported long delays in receiving payments from the Medicare and TRICARE programs, with some practices not having been paid since November 2011. To help alleviate the problem, MGMA is urging HHS to instruct all Medicare Administrative Contractors (MACs) to provide advance payments to practices that are struggling to meet the mandate and as a measure to keep them solvent in the interim.

“The most immediate and pressing concern is that there is no money coming in the door for many practices,” said Rob Tennant, senior policy advisor with MGMA. “So the advance payment issue is absolutely critical. I was on the phone the other day with a practice administrator who said this is the first time in 20 years they haven’t been able to pay their rent.”

The Centers for Medicare & Medicaid Services refused to comment on the requests by MGMA. In an email response to an interview request, a CMS spokesman said, “HHS has a correspondence response process, and CMS will be contributing to development of HHS’s response. In the meantime, MGMA’s letter is considered open correspondence and we can't comment.”

But that won’t help the likes of the doctors and employees at New York Urological Associates PC, based in Manhattan. According to practice manager Janet Bernstein, she began noticing payment irregularities in mid-December and the problems don’t seem to be abating.

“We send claims three times a week and for some of the claims there is not record of them (with the MAC),” Bernstein said. “I’m not sure why there is no record for some days and not others.”

When interviewed, Bernstein noted that these “lost” claims amounted to about $100,000. “If this goes on for a couple more months, I’m not sure what we are going to do.”

To help mitigate the financial hardship some practices are enduring, MGMA provided HHS with a long list of other necessary steps the agency should take including allowing MACs and clearinghouses to accept and adjudicate 5010 claims even if they don’t have all the required data; instructing MACs to expedite all claim whether paper or electronic and to process claims in batch mode; and instructing MACs to provide adequate manpower to call centers to ensure timely service.

According to Tennant some practices may be more at risk than others, especially smaller practices and those whose service include providing very expensive medications, such as oncology practices.

“It’s getting to the point where this is not just an inconvenience,” Tennant noted. “Now, if some practices can’t afford some of these medications, which are literally life-saving, it could potentially become a patient safety issue.”