5010 and Its Impact on US Healthcare

Niurka Moreno
February 14, 2013 — 1,094 views  
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HIPAA 5010 impacted the US healthcare industry in a way that has not been seen in quite some time. The impact on medical billing and collections and some of the managed care solutions has been rather dramatic, and it has included problems such as delayed payments and a general lack of organization and co-ordination. The switch to version 5010 has definitely had a large impact on the overall US medical claims processing continuum.

EDI transactions have a lot of data that is transferred from different trading partners, so it's of utmost importance to make sure that there are no glitches that pop up along the way. Although there was a ‘pilot phase' implemented for this new change in the latter half of 2011, there was not a lot of time and effort put into the planning stages of the ‘pilot' program. This led to a lack of productivity once 5010 was adopted starting 1st January, 2012.

Measuring the impact of 5010

The best way to interpret the overall impact of 5010 is to do a cost-benefit analysis. Everyone should have prepared themselves better for 5010 because there were a lot of problems for people who did not set themselves up properly from the beginning. To avoid delays and software glitches at the last moment in the future, you have to prepare for the forthcoming changes with an action plan right now, relevant for everyone in healthcare, including those involved in medical billing and collections.

Version 5010 will have a large impact on the adoption of ICD-10, that is one of the reasons for the adoption of 5010 starting 2012 as a preparatory step for the adoption of ICD-10 in October, 2014 (earlier  October, 2013). Collaboration with business partners is of vital importance because businesses need to make sure that they are on the same page as everyone else. Revenue impact considerations also have to be made because every business has to keep focused on what kind of impact this change will have on their overall revenues in medical billing and collections.  Outsource Medical Billing and Medical Coding companies had to do this on behalf of most office-based Providers, as they are fully responsible for their client's collections.

Who gets affected by 5010?

The change to version 5010 has impacted every entity in the US healthcare industry.  Some of the entities that did not have a strong 5010 implementation roadmap suffered the consequences – delayed payments, missing claims, missing ERAs/EOBs and so on.  It took almost the entire first quarter of this year to set right all the missing pieces in the 5010 puzzle.

Lessons from the 5010 implementation

  • Preparations to be made during the ‘pilot' phase of the project, if available.
  • Multi-stage testing under different scenarios and time frames.
  • Have a plan B during the go ‘live', in case there is a glitch in the software or some other unexpected disruption.

So, all US based medical claims processing entities need to put in place an implementation roadmap whenever a change of this magnitude happens again.  Hope the ICD-10 implementation is a smoother transition than what 5010 turned out to be.  


Niurka Moreno