5010 “Ready or Not”

1. 5010 “Ready or Not” Lakeland Regional Medical Center Tips and FAQ’s

2. Timeline • As of 11/11/11, there are 39 days left • Medicare live 10/01/2011 – returning remits available as well in 5010 • Florida Medicaid live 10/01/2011 – returning remits available as well in 5010 • Big 5 commercial payers live by 12/01/11 – Including Blue Cross, United Health Care, Humana, Aetna and Cigna

3. Gap Analysis results • Field by field comparison from current 4010A1 format to 5010 • Performed in 2009 in preparation • Several new segments or loops • HIS systems may still be coded to require entry on registration • BEWARE of deleted segments or loops • If deleted segments or loops are passed in productions claims, the claims have been proven to fail • Double check with billing scrubber and clearinghouse

4. Frequent errors • Feedback from Siemens user groups • Small percentage of Florida Medicaid claims getting through • Usually secondary physician ID related • Medicare claims seem to be accepted initially but large percentages are going into RTP • Feedback suggests these are based around the removed Pay to Provider segment (see Gap Analysis) • Feedback also suggests that there are many POA errors • Feedback from Relay Health • List serve documentation as it is assembled • 5010 site available and updated weekly

5. FAQ’s • What can I expect from this conversion? • What effect can it have on my cash flow? • What are the major issues with testing? • What kind of test results are being revealed?

6. What can I expect from this conversion? • PFS/IT departments will work to make it as invisible and painless as possible • However, ensure adequate resources are allocated to shoring up changes in bill scrubber and follow up with payers for errors • Intensive processing scrutiny from Medicare, Medicaid and Big 5 payers – expect rebills • Expect to allocate staff in the short term to compensate for the detailed research when claims are returned or rejected • Expect payment delays

7. What effect can it have on my cash flow? • As with any billing change, this has the potential for huge impact • If not properly addressed - days or even weeks of cash delays • Ensure that claims are properly translated or submitted via bill scrubbers to avoid rejections • Faster follow up claims turnover and rebilling will greatly reduce the impact • Watch error reports • Everyone is going through this together – there will be issues

8. What are major issues with testing? • User group feedback suggests that there are still major billing scrubbers applying 4010A1 edits to new 5010 claims • It is imperative that the payer testing be completed with properly translated or imported claims • Not a 4010A1 with the new 5010 fields • Not a 4010A1 with 5010 headers and footers • Physician ID issues • ONLY NPI numbers are now being accepted – HIS updates may be necessary if not all are collected

9. What kind of test results are being revealed? • User group feedback indicates that Pay to Provider and Secondary Physician (Non-NPI) ID’s are the biggest problems • Relay Health information indicates: • NPI issues • Separately enumerated subparts must be reported as the correct billing provider • Individual provider NPI’s are required (physician) • COB Balancing • Must indicate how much other payer paid AND patient responsibility/amount due • Admit date – Inpatient ONLY

10. Test results (cont.) • Relay Health also indicates: • NDC Drug quantity • If NDC present, then QTY required • Patient Reason for visit • Required for outpatients • Will reject if not appropriate for revenue code bill type combinations

11. Summary: …Be ready • Don’t assume this will be invisible • Allocate staff • Prepare to touch claims several times before acceptance • Watch rejection reports • Payers are going to have issues too, and may erroneously reject your claims • Work closely with billing vendor and clearinghouse • Properly prepared billing and follow up team can greatly reduce cash flow impact