5010 Nightmare

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.


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