Uncertainty in enforcement, creates business risk for Medical Practices not yet compliant.

Now more than ever, medical practices need to partner with IT professionals who understand the mandates, regulation and incentive programs that are affecting their business.  On January 1st, 2012, the new federally mandated HIPAA version 5010 format for electronic billing went into effect.  However, many payers, clearing houses, EPM software venders and medical practices are still not compliant and unable to bill correctly to the specifications of this format.

So far, this has not affected most claim reimbursements thanks to a 90-day grace period on the 5010 compliance date, granted by the federal Department of Health and Human Services.  Unfortunately, many healthcare facilities are not aware that the grace period, as defined, does NOT actually protect them from having claims rejected for 5010 non-compliance.  According to the notice, the Department of Health and Human Services makes clear that deadline for compliance remains January 1st, 2012.   The grace period is only a statement of non-enforcement of compliance, allowing insurance payers flexibility in their rollouts.  Most large insurance payers have spent most of 2011 testing and are in fact ready to receive 5010 billing claims but have decided to continue to support both 4010 and 5010 transactions through the grace period.  Others, like the State of Washington’s DSHS have stated that regardless of the grace period offered, they are only accepting the new standard in compliance with the mandate of January 1st, 2012.