Hospital Margins in Jeopardy as 5010, ICD-10 Deadlines Loom

“Some people are ready and some are just totally in the dark. I’ve talked to a few people who didn’t even know what 5010 was about; that concerns me,” says Landes. “So, we’re getting a poll out to see where physicians in our IPA are in this process.”

Indeed, Intelligence Report respondents cited physician cooperation as the No. 1 challenge providers expect.

Unprepared payers, too, could trip up even those providers who are further along in their efforts, notes Albert Oriol, vice president and chief information officer at 442-licensed-bed Rady Children’s Hospital and Health Center in San Diego.

Providers will need to test each outgoing 5010 transaction and adjust the setup and process as needed. To do that, however, the payer needs to be 5010 ready now. Oriol says that the testing process consists of submitting test claim files to each payer and doing so as specified by each payer—and the process can vary by payer. The same process will also need to take place with ICD-10. 

It’s the testing process that will likely bottleneck many providers, especially in the last few months of 2011, says Oriol. And as 2012 begins, some payers may not allow providers who haven’t done the testing to submit live claims until they successfully do the testing.

“Some payers are notorious for not conforming to the standards,” says Oriol. “And getting the attention from each payer to be able to test everything requires a lot of coordination. It’s not enough to send a file; you need to test a full cycle, and at some point people may not be able to get in the [payers’] queues to do it.”

Regression testing, a lower level of testing, may suffice for some providers as an alternative to direct testing with payers for 5010, Oriol says. However, he says, payers and providers should be prepared to work in parallel environments to be sure that claims continue to be submitted and paid.