HIPAA 5010 Transition – is a distinct “pilot” phase necessary?
HIPAA 5010 and ICD 10 are impacting the healthcare industry in an unprecedented way. The scale of the impact to systems and processes is such that there is no scope for debate on the need for upfront risk management strategies. However, I think the need for a distinct pilot phase as part of the risk mitigation strategy is debatable.
Healthcare EDI transactions involve loads of data, in a “many to many” interaction between trading partners. It is imperative that a small mismatch in the message format between trading partners or a small glitch in the claims processing rules can cause significant reduction in straight thru processing and its repercussions on loss of productivity and customer dissatisfaction. Due to lack of commitment and planning for a dedicated pilot phase, I have seen valid large value claims getting stuck in the chain of processes during the 4010 implementation – such incidents caused provider dissatisfaction and required backend updates to send the payment out after months of delay and follow up by the provider’s office. A distinct pilot phase between key trading partners will reduce the chances of such incidents on a large scale.
On the other hand, a distinct pilot phase requires significant investment. Key production systems will need to be replicated on a parallel pilot environment. This will require hardware, software and manpower investment. Additionally, the pilot phase will require equal amount of commitment from the trading partners – which might be difficult to guarantee in a “many to many” relationship.
So, a cost/benefit analysis should be carried out to determine the need for a distinct pilot phase. Experience with implementing the 4010A1 standards should be leveraged while making the call. There should be adequate focus on system and integration testing, if the decision to go without a distinct pilot phase is made.
Your thoughts and ideas on this topic are welcome!
Comments
From payer perspective, a pilot phase of execution is necessary with the current level of changes coming up in 5010. With this approach we have some issues to understand. Most of the current 4010 transactions are customized to a certain level between the payers and trading partners. With the NPI Mandate in 2005, POA mandates in 2008, payers adopted more specific implementation guides between various trading partners and payer to payer EDI transactions.
The problem lies how to execute this pilot phase by a payer with multiple trading partners and customized implementation guides and on multiple transactions. Even if we execute a pilot phase, covering all the business scenarios in the 5010 transactions is a challenge. There will be issues related to infrastructure upgrade, resource assignment for a period of 3-4 years (initial pilot phase and then continue same resources for next phases) and dual transaction standard acceptance. We all know the number of issues payers and providers have faced during the NPI mandate implementation and dual acceptance mode (the legacy provider number and NPI).
The most significant problem is, payers do not have an impact analysis readily available on the downstream applications (claims adjudication, payment, pricing) on changing/editing a particular field in EDIT transaction. A simple analysis of accepting a new value from EDI transaction and loading to downstream applications will need significant amount of SME time from different applications. For example during the POA mandate (Present On Admission), in order to research/analyze and write requirements related accepting POA, one of the major US healthcare company took around 8 person months of SME effort analyzing 20-25 different backend application . Not e that we have hundreds of changes in 5010 transactions and we have huge code inventory from multiple applications to analyze for the changes. As the 5010 changes vary from technical, business and functional a lot of effort needs to be spent on analysis by Business Analysts SMEs, DBAs, and other supporting Project management activities.
Various impact assessment studies over the 5010/ICD10 mandates have shown that payers and providers can see the business benefits over a period of next 10 years. There will be less business benefits in the first 2-3 years after the compliance date. So a through cost benefit analysis must be performed in executing the project as a pilot phase or attain full compliance.
Posted by: siva kumar Reddy Tunga | June 30, 2009 9:20 AM
From both Payer and Provider perspective, there should be an implementation of the 5010 so that there can be a sync and full benefits derived from it. The vending partners as well as the providers should be made compliant even for a pilot phase.
May be for just the pilot phase, a quick and dirty approach can be used wherein the changes can be plugged by using standard qualifiers.
Posted by: Ajay Srinivas | August 31, 2009 11:33 AM