|
Beginning on January 1, 2012, a federal mandate requires health plans, clearinghouses, and providers to use new standards in electronically conducting certain health care administrative transactions at the heart of daily operations, including claims, remittance, eligibility, and claims status requests and responses.
Upgrading from the current HIPAA 4010A1 transaction standards to the new 5010 standards addresses several key goals:
- Increase transaction uniformity
- Support pay for performance
- Streamline reimbursement transactions
As the deadline approaches, affected health care organizations need to upgrade and test their claims management systems to accommodate 5010 and prevent operational disruptions.
What’s driving the change
Two key factors prompted the upgrade to 5010: 1) the government and industry’s shared goal of providing higher quality, lower cost health care, and 2) the need for a comprehensive electronic data exchange environment for the vastly expanded ICD-10-CM and PCS code set transition mandated for compliance by October 1, 2013.
Consistent compliance standards are critical to both objectives.
The 4010 compliance standard was not fully enforced, and many proprietary adaptations were implemented, forcing providers to interpret and reconcile disparate billing and reimbursement processes and systems.
Approximately 12 percent to 22 percent of premium dollars are spent on these administrative expenses, many of which are rooted in manual processes. Reductions in these costs could substantially enhance the bottom line and potentially reduce the overall cost of health care.
|