MGMA call for 90-day 5010 extension draws wrong conclusion, would negatively impact providers

MGMA’s request to delay the 5010 enforcement penalties for another 90 days would give ill prepared payors more time to convert to 5010, but no consideration for providers already experiencing significant reimbursement issues. Penalties and risks for payors and providers are misaligned. Providers bear the full cost of lost and delayed revenue from payors trying to meet conversion deadlines in order to avoid penalties unrelated to conversion quality.

What providers need now is an option to get paid when a payor is unable to process trouble free 5010 files, such as availability of a parallel 4010 processing option until such time that payors demonstrate error-free processing of 5010 files. There should be no more extensions for payors, and they should be penalized for 5010 processing errors. Payors who cannot demonstrate clean 5010 processing, should not be able to force a hard cut-over to 5010. Most importantly and after experiences noted to date by XiFin and other claims processing entities, it should be obvious that the down convert/up convert option is not viable and should not be used by payors or providers. Payors cannot profess to be 5010 compliant if they or their clearinghouse are down converting files.

For providers, it is strongly recommended that 5010 production files be sent to payors having demonstrated trouble-free processing as early as possible to allow for needed time to work out all the kinks on their side. Select two or three payors for the live clean up phase and once successful, begin converting to other trouble-free payors. Delaying going into 5010 production with payors who are ready will put a providers at risk when conversions deadlines are not within their control.

Recommendations for CMS 1) Establish a firm timeline for payors first and a certification mechanism for trouble free processing of required 5010 files for payors prior to inviting provider side testing 2) Establish an adequate testing time frame for providers post-payor certification 3) Establish a penalty phase for payors that cannot implement trouble-free 5010 processing as demonstrated by meeting certain criteria associated with payment delays. 4) Determine standard, and not payor-determined, cut-over protocols for all payors that facilitate parallel processing for providers until certain criteria have been met, demonstrating trouble-free processing.