Archive for February, 2012

5010 Tip #2

February 29, 2012

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment.  That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012.  I know.  Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain.  I am sorry.  I wish I could fix it with a magic wand, however, I can’t.  I can provide you a few pieces of information that might  help you get some cash flow turnaround quickly.  The next few weeks I am going to try to post a few tips on 5010 and hopefully provide you some resources to help you make headway through to get some answers to your problems.

Who is your clearinghouse?

Do they have a newsletter?

Do they have a blog?

Do they have a discussion board?

Do they send you weekly tips and suggestions to improve your claims?

Do they have webinars for you to attend (either free of charge or at a cost)?

Have you utilized everything they offer?

The only way to know is to research it and find out.  If you don’t know…google them and see where it goes.  You are liable to learn a lot in a short time frame and maybe even get a nugget that will help you with a current problem you are experiencing.

Come back next week for another 5010 Tip!


Podcast: Get More Done in Less Time

February 28, 2012

Absorb what is useful, discard what is not, add what is uniquely your own.  – Bruce Lee

Do you feel you have so much to do and so little time to do it?  Your energy is your most asset.  Our productivity and our happiness suffers when we don’t take care of it.  We have to be intentional in when to use it and when to save it.  We all have the same amount of time.  Focus your energy…

A great article and podcast by one of my friends, Pam Weatherford, owner of D3Seminars.  She has a very popular class called Cut the CRAP: Get More Done in Less Time.  This is a short review of the article and podcast, but you can read it and/or listen to it here.  [My comments are entered in these brackets…and yes, I am one of the chics that join her regularly for a Yogurt Brainstorming Session!]

What gets in our way?  Entrepreneurs think they need to do everything themselves.  You have to learn to delegate.

C – Complete It

R – Refuse It

A – Assign It

P – Pitch it

Complete, say No to, Delegate or Throw Away?  [Wow is it really that simple?]  It is not always about doing more.  Don’t get bogged down with everything that comes your way.  Set boundaries.  Being an Entrepreneur is hard work.  We don’t always know how to say no.  Where can I put 20% of my time & effort to get 80% of results so that you are more efficient and effective. Prioritize and focus on taking one bite at a time.  You have to answer what is the highest and best use of my time and do those things.  It helps to have a Mentor or a Coach when you get stuck in the weeds.  You have to stay on track and not get overwhelmed.

Are you running to stand still?  Or are you running on the treadmill?  Take a moment to breathe.  Relax.  Refocus.

Sometimes we are just scarred to say no.  We have to practice this.  If it doesn’t resonate, you need to say: “I am sorry, that doesn’t fit in with where I am going.” [I forget, it is my life, not yours and God is the One I am following on this Journey.  I need to learn that No is a word and a complete sentence.]

Highly productive people stay focused.  Stay away from the bright shiny objects syndrome.  Have a niche.  Do what you are great at and passionate about.  [What a loaded reminder…focused on what is important, not what is not important. Glitter gets you nowhere, everytime. ]

Eat the frog.

It is an every day process.  Think about your focus, remember it is not about working harder.  Don’t fight it if you are not feeling it.

You have to take care of yourself to be your best.

[I have wanted to take this class several times she has offered it; however every time that it has been offered it has been a conflict of interest with other business and client events…so this was a teaser that wet my appetite to review cutting the stuff out of my life!]

What is the NUCC?

February 27, 2012

The NUCC was created to develop a standardized data set for use by the professional health care community to transmit claim and encounter information to and from all third-party payers. It is chaired by the American Medical Association (AMA), with the Centers for Medicare & Medicaid Services (CMS) as a critical partner. The NUCC is a diverse group of health care industry stakeholders representing providers, payers, designated standards maintenance organizations, public health organizations, and vendors.

The NUCC was formally named in the administrative simplification section of the Health Insurance Portability and Accountability Act (HIPAA) of 1996, Public Law 104-191 (P.L. 104-191) as one of the organizations to be consulted by the American National Standards Institute’s accredited Standards Developing Organizations (SDOs) and the Secretary of Health and Human Services (HHS) as they develop, adopt, or modify national standards for health care transactions. The NUCC was also named as one of the HIPAA Designated Standards Maintenance Organizations (DSMO) to maintain the HIPAA transaction standards. A DSMO Web site has been established to submit requests for changes to the HIPAA
implementation guides. For more information regarding the DSMO groups and the process for submitting change requests go to Therefore, the NUCC is intended to have an authoritative voice regarding
national standard content and data definitions for professional health care claims in the United States. The NUCC’s recommendations in this area are explicitly designed to complement and expedite the work of the ASC
X12N in complying with the provisions of P.L. 104-191. The NUCC is comprised of the key parties affected by health care electronic data interchange (EDI) – those at either end of a health care transaction, generally payers and providers. Criteria for membership include a national scope and representation of a unique constituency affected by health care EDI, with an emphasis on maintaining or enhancing the provider/payer balance in the original NUCC composition. Each NUCC member is intended to represent the perspective of the sponsoring organization and the applicable constituency. Representatives are responsible for communicating information between the NUCC and the group(s) they represent.
The following organizations serve on the NUCC as voting members:

  • American Medical Association – provider
  • American Academy of Physician Assistants (Non-Physician Provider) – provider
  • American Association of Homecare – provider
  • Medical Group Management Association – provider
  • State Medical Association – provider
  • Veterans Health Administration – provider
  • Alliance for Managed Care – payer
  • America’s Health Insurance Plans – payer
  • Blue Cross Blue Shield Association – payer
  • Centers for Medicare and Medicaid Services – Medicaid – payer
  • Centers for Medicare and Medicaid Services – Medicare – payer
  • National Association of State Medicaid Directors – payer
  • ANSI ASC X12 Insurance Subcommittee – designated standards maintenance organization
  • Dental Content Committee – designated standards maintenance organization
  • Health Level Seven – designated standards maintenance organization
  • National Council for Prescription Drug Programs – designated standards maintenance organization
  • National Uniform Billing Committee – designated standards maintenance organization
  • Public Health/Public Health Services Research – state perspective
  • Public Health/Public Health Services Research – federal perspective
  • Health Information Management Systems Society Association for Electronic Health Care Transactions – vendor

AAPC 5010 Survey Results

February 24, 2012

The AAPC did a survey last week, which I participated in for each of my clients.  I let you all know about it in this post.  The results were released today and if you are interested, click this link and you can review the data.  It is interesting if you care to know what everyone else is experiencing.


Letter from a Provider: Dear Center for Medicare and Medicaid Services

February 24, 2012

An Oklahoma provider was the first to receive EHR Incentive Program funds from Medicaid.  She shares her story here on a letter she would write to Medicare and Medicaid Services if she could as follows: Dear Center for Medicare and Medicaid Services.  She would send it, if they would listen.  If they cared.  It is worth reading.

We all need to support each other!



February 23, 2012

Great leaders are almost always great simplifiers, who can cut through argument, debate, and doubt to offer a solution everybody can understand.

– Colin Powell

5010 Tip #1

February 22, 2012

You went to an EMR/EHR in preparation for the regulation changes in the Healthcare Industry for 2014 and to avoid a deduction in Medicare Claims Payment.  That was a huge financial cost to your practice and the last thing you anticipated was having a cash flow crisis to the industry electronic claim file changes that CMS ruled would take place January 1st, 2012.  I know.  Remember, like you, I am experiencing the 5010 fiasco I blogged about here with my clients, so I totally relate to your pain.  I am sorry.  I wish I could fix it with a magic wand, however, I can’t.  I can provide you a few pieces of information that might  help you get some cash flow turnaround quickly.  The next few weeks I am going to try to post a few tips on 5010 and hopefully provide you some resources to help you make headway through to get some answers to your problems.

Who is your biggest Insurance Carrier?  Is it a commercial insurance carrier or government program?

Do you know if they have the ability for you to file claims directly on their online portal?  If so…have you considered this option?  Did you know about 50% of them do?

Are you aware that claims are processed in 24-72 hours once submitted on this site and that you have a check within 7-10 days?

If the insurance carrier does not have an online portal to be able to submit claims to them, do you know if the insurance carrier has any free software you can use to submit claims?  Medicare does.  It is called PC ACE PRO 32.  You have to have an EDI Agreement in place directly with them and get a unique submitter ID#; however, once you get that, claims are paid within 14days like clockwork.  It is NOT a Practice Management system, it is simply a tool to submit claims…but if you are not getting paid through your clearinghouse it is a viable option to consider in the interim.

If I were to have given CMS any feedback on preparation for 5010, they should have made this an available option and a requirement that all insurance carriers have an option to be able to upload raw data directly to them and/or their clearinghouse along with a portal for online claim submission.

Come back next week for another 5010 Tip!

What Doctors Do.

February 21, 2012

What do you think your Doctor does?

 (click in the box if image does not display)

CMS Important Update regarding 5010

February 20, 2012

With the implementation of Accredited Standards Committee (ASC) X12 Version 5010, several concerns have been identified that may impact certain activities surrounding the transition.  Medicare has published a Guidance and Clarification for Version 5010 Implementations here.

5010 Nightmare

February 20, 2012

I have been in the Medical Industry for 16 years and I have seen changes over time affect our industry and create problems of such a major impact that you have issues that are referred to as a Nightmare.  Nightmares both literally and figuratively.  Horrific nightmares that all of us dread and seriously hope we never have to face.

This blog has been a way I have communicated tips, resources, and quotes of motivation to inspire all of us in our quest to provide excellent service to our clients, providers and employers.  I read a blog post yesterday by a physician that shared many things they are experiencing with the horrific changes to 5010 on a personal level and how if they can’t get resolution soon, they will have to close their doors.  I read such an article via my AMA email subscription two weeks ago, but hadn’t had a personal story to attach it to.  Having now read that, it made me realize that I have never utilized my business blog for such purposes…however, in light of the serious fiasco of 5010, it prompted me to change and share a few things I have learned along the way to try to encourage my colleagues and providers that are beat down, scarred stiff, discouraged and ready to quit (either because they have to financially or because they are done with this mess).

With the approaching deadline of 5010 Implementation set forth originally by CMS as January 1st, 2012, I told each of my clients that this change will either be a hoopla (a big deal over nothing) or it will be a fiasco (a horrific mess).  For most of my clients, it has been the latter.  A fiasco that has caused Cash Flow Crisis Issues beyond words.

For all of my clients, very little of this could have been avoided.  Why you ask?  Well, all but one of them utilize a software vendor to transmit their claims to the clearinghouse.  Only one of them submits directly to the carrier.  When you utilize a software vendor, you are at their mercy as to what testing they have done, what compliance steps they have taken, what progress they made during “testing phase”, how proactive they are at resolving issues, what information they communicate or do not communicate to the providers, what changes they make without letting you know, along with how effective they are at trouble shooting, let alone their personal experience and knowledge of your specific specialty and/or industry, along with carrier requirements.  Many times, these representatives have the “basic” foundation and understanding of the claims files and data required.  Most of the time the Support Team and/or Customer Service Representatives do not have specific experience to your industry or know your states requirements on a payer level.  If you have worked with a Support Team and Customer Service Representative that does, I applaud you.  No, I don’t applaud you, I am jealous of you because by not working with Support Team and Customer Service Representatives that have that experience and understanding, that only adds the the stress.  For the most part since I have been working on this 5010 stuff beginning in October 2011, I have not.  Utilizing a software vendor and a clearinghouse means that you pay them to be uptodate and compliant on all levels.  That means when they state they provide a service to all industries, they do just that.  When their website says they have completed testing, are compliant, ready for the implementation of the conversion and will work with you to prevent any issues, they should be.  This means they have to fix your issues.  This means that you do not have to figure out what data is wrong.  Or does it?

Let me just tell you that I never dreamed that I would be:

  • analyzing the raw data to find the missing errors because you get told by the EDI Team that they don’t find an issue or they don’t know what is causing the issue, but yet you clearly are getting rejections
  • they pawn you off asking if you read the latest broadcast message that this is a “known issue”, yet they have no resolution or fix yet for this “known issue”
  • educating these Support Team and/or Customer Service representatives on what is wrong and required per ANSI5010 vs ANSI4010 requirements and in many cases providing hard core information to substantiate it because they argue that they have no record of this or that being a requirement
  • providing proof to a Carrier that they rejected my claims by providing them the exact reports they sent back to our clearinghouse, when they state they never got our original claims but we clearly have “Carrier Reports” which are responses directly from the Carrier
  • providing the supposed experts and guru’s on the technical team the 296 page CMS document file on what is required on a HCFA1500/CMS1500 Claim Form to submit a paper claim because they told me that was not a Medicare requirement to be printing on the form even though I showed them the denial from Medicare
  • get into arguments with the EDI team when they state they never knew this stuff and it must be “new” (yes some of it is new, some of it is old requirements being transmitted in a new format but the requirement is not new)
  • when provided an answer that I know will not fix it having to lay out the ground work, be patient and realize that you will have to educate them as a teacher does a student as to why that “fix” will not fix it
  • etc

So what steps would I encourage you to take during this 5010 fiasco?

  1. Know if your carrier is in 5010 production mode or still in test mode.
  2. Confirm if you clearinghouse is converting your files from 4010 to 5010 for you or if you have to make the change in your database for the data to be exported correctly.
  3. Locate your carriers requirements for transmitting a claim electronically and also obtain their requirements for paper claims.  CMS has their information posted out on the internet, it is not a secret.  Each carrier will provide you their requirements if you just make the phone call to them.  All it takes is for you to call them, tell them you want to make sure you are in compliance and ask for their’s is not published on the internet or through the provider portal.
  4. Take the information you get on your carriers requirements and provide that information back to your software vendor and/or clearinghouse and assist them at making the changes.  Believe me, if you do this, you will get resolution much quicker.
  5. If you have the option to file claims directly on the carrier’s website, even if this is double entry because you have loaded the claim in your database and must re-enter the information in their online portal, do so, you will be paid very quickly, on average 7-14days out.
  6. When you know you have the correct information and the EDI team or Support Team don’t provide resolution, hold your ground.  Ask to speak to a manager.  Tell them the case needs to be escalated to a Tier 2 Representative.  Tell them you are sorry, but that won’t fix the problem.  Do another test to show them it doesn’t.  Don’t be afraid to clearly provide answers that “the fix” is not a fix.
  7. Stay on top of the issues.  Give them 24-48hours to respond, if they don’t call and email them.  They will learn after repeated phone calls from you that you mean business, won’t be put off and want resolution.  Remember:  The squeaky wheel is the one that gets the grease.
  8. If you don’t get a response to your claims that you have submitted, drop that bad boy to paper and mail it to the carrier.
  9. Don’t give up!!!  As Dave Ramsey says “In the story of the Tortoise and the Hare, every time I read the book, the Hare always wins the race.”  Meaning:  Slow.  Steady, Consistent, Focused, Determination  = Success
  10. Be patient.  Keep the big picture in mind.  Work this in bite size chunks.  We will win on this conversion to 5010!  I am confident we will!!!


What issues are you experiencing with 5010?

What steps have you done to get success?

Share tips below for other colleagues.  If you wish to write a guest post on my blog, contact me.

HSA Data for 2012

February 17, 2012

Do you have an HSA?  If you do, you will be interested in knowing the information on the update on your contributions for the calendar year of 2012…

For 2012, an individual can contribute up to $3,100 to their HSA, and a family can contribute up to $6,250. Minimum high deductible health plan deductible requirements remain the same, at $1,200 for an individual and $2,400 for a family. Maximum out-of-pocket for HSA plans in the 2012 calendar year is $6,050 for an individual and $12,100 for a family.

Do you have an HSA?  Do you utilize it as one?  If you don’t know if it is a good thing for you and your tax plan, consider talking to both your Insurance Agent and your CPA.  They will advise you in your circumstances on what would be best.

AAPC Survey re:5010 issues

February 16, 2012

If you are a Medical Practice and are experiencing 5010 issue, may I encourage you to do this quick survey?  If all of us contribute on the level we are experiencing issues, we may get some of our support groups to rally for us!  Please join me in doing one small step toward that.  Just click on this link:

AAPC Survey

Thanks a bunch!


February 16, 2012

If life was so easy that you could just go buy success, there would be a lot more successful companies in the world. Successful enterprises are built from the ground up.

– Lou Gerstner, IBM CEO

Meaningful Use Deadline…

February 14, 2012

Physicians who met the reporting requirements for Medicare’s meaningful use program for electronic health records (EHR) in 2011 have until February 29, 2012 to register and attest to meeting meaningful use requirements to receive payments for 2011 through the Medicare & Medicaid EHR Incentive Program Registration and Attestation System.

February 29, 2012 also is the deadline to submit any pending Medicare Part B claims from 2011, as the Centers for Medicare & Medicaid Services (CMS) allows 60 days after December 31, 2011, for all pending claims to be processed.


February 13, 2012
It’s better to hang out with people better than you. Pick out associates whose behavior is better than yours, and you’ll drift in that direction.
– Warren Buffett, Berkshire Hathaway, CEO


February 9, 2012

A leader seeks to communicate his vision to his followers. He captures their attention with his optimistic intuition of possible solutions to their needs. He influences them by the dynamism of his faith. He demonstrates confidence that the challenge can be met, the needs resolved, the crisis overcome.

– John Haggai

Top 5010 Issues

February 8, 2012

Many physician practices have reported numerous problems across various areas of the United States stemming from the transition to Version 5010. The most frequently reported problems have involved:

  • Issues with practice management and/or billing systems that showed no problems during the testing phase with their MAC, but once the practice moved into production phase, found their claims being rejected
  • Issues with secondary payers
  • Rejections due to various address issues (pay-to address being stripped/lost from claims; pay to address can no longer be the same as billing address; no PO Box address)
  • Crosswalk NPI numbers not being recognized
  • “Lost” claims with Medicare Administrative Contractors (MACs)
  • Old submitter validation information not being transferred
  • Certain “not otherwise specified” claims being denied due to not having a description on the claim (CMS sent a notice of correction of this issue January 27, 2012)
  • Sporadic payment of re-submitted claims (with no explanation for rejections)
  • Protracted call hold times (most typically 1-2 hours) when attempting to contact Medicare Administrative Contractors (MACs) for further explanation of unpaid and rejected claims (a problem that dates as far back as November 2011)
  • Unsuccessful claims processing (with no reason cited for rejection) despite using a “submitter” that was approved after successful testing with CMS

Many providers report not having been paid by Medicare and TRICARE since as far back as November 2011 as a result of Version 5010 issues.  They also are not getting all the Carrier Reports back to confirm accepted and rejected status of the transmission of their claims.  Many are experiencing rejections that the Clearinghouse can not explain.  These issues must be monitored and steps taken to ensure that claims are getting processed through to the carriers as quickly as possible.

What have you experienced with the transition of 4010 to 5010 format?  We would love to hear your feedback.

Denials and Issues with 5010

February 6, 2012

As a Medical Practice, you are aware of the impact that our industry is facing as of 01.01.2012…conversion of Electronic Files from the 4010 to the 5010 formats.  The American Medical Association is aware that this is creating many denials and issues with 5010 and therefore has put out documentation on what you can do if you are experiencing claims processing issues.  Please read below:

Since the deadline on January 1, 2012 to convert to the Health Insurance Portability and Accountability Act (HIPAA) Version 5010 transactions, some physicians have been experiencing issues with their claims processing, resulting in lack of payments.

The AMA is aware of issues with claims processing related to the 5010 transition and is addressing these issues directly with the Centers for Medicare and Medicaid Services (CMS). Please inform the AMA and CMS of your issues:

  • Report the problems you are having to the AMA with this form at
  • Visit to access additional complaint forms, including the Centers for Medicare and Medicaid Services complaint form.
  • Submit your problem to for issues you are having with Medicare.

Until these issues are resolved, the following are action items that physician practices can take if they are having issues with their claims and interruptions in their cash flow:

  • If using a billing service or clearinghouse, contact the billing service or clearinghouse to understand where the problem is occurring. Is it related to the data you are submitting? Is it due to the payers’ processing of the claims?
  • If you identify a problem with your practice management system, contact your vendor to have the problem resolved.
  • If you submit your claims directly to the payer, contact the payer to understand where the problem is occurring. Is it related to the data you are submitting? Is it related to problems within their adjudication system?
  • Contact a financial institution about establishing a line of credit.
  • Consider submitting paper claim forms to those payers that will accept them.

What are you doing to stay on top of the changes with 5010?  Are you seeing any impact on your practice?  If you have any tips for other Medical Practices, we would love you to share your ideas below.  We are a community out to help each other be successful!


February 2, 2012

Goals are dreams with deadlines. ― Dottie Walters