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Providers who cannot meet the January 2012 deadline to migrate to HIPAA 5010 electronic transaction standards should develop contingency plans with their trading partners that will provide a stopgap until they can meet full compliance, the Healthcare Information and Management System Society (HIMSS) said.

HIMSS outlined its position in a letter, dated September 19, to Justine M. Carr, chairperson of the National Committee on Vital and Health Statistics (NCVHS). NCVHS serves as the statutory public advisory body to the Department of Health and Human Services (HHS) secretary in the area of health data and statistics.

In HIMSS' view, based on feedback from healthcare provider members, many clinicians who will be required on January 1, 2012 to conduct HIPAA electronic transactions, including claims submission, eligibility, claims status, remittance advice, and referral authorizations, will not be prepared to do so using the upgraded 5010 version.

"Providers and health plans will most likely develop their own internal contingency plans in order to ensure that providers are able to continue their business operations with minimal disruption," Juliet A. Santos, senior director, HIMSS business-centered systems, told InformationWeek Healthcare. "Without these pre-agreed contingency plans with their trading partners, providers may experience rejections resulting in delayed or non-payment for non-compliant claims."

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The letter says "provider organizations will be at risk of lower or non-reimbursement for submitted claims for those who have not implemented a process to submit compliant 5010 transactions." Additionally, providers already testing their systems are facing many difficulties including:

-- Trading partners need to continue side-by-side comparisons of the 4010 and 5010 transaction versions after the January industry go-live date to determine problems or issues that need to be addressed as integrated systems processing changes are tested and challenged in the production environment.

-- If alternatives for claims submission in 5010 have not been identified by providers to meet the 5010 compliance date, this will result in other complexities that may ultimately impact ICD-10 implementation and compliance. As ICD-10 cannot be implemented until 5010 compliance is achieved, trading partners (payers, providers, clearinghouses, billing agents, and others) should be well into transaction testing, but with errata software updates creating delays in testing into the second quarter of this year, and 5010 software implementation running behind projected timelines, stakeholders may face further difficulties implementing ICD-10.

-- A number of data elements cannot be readily derived from 4010. Therefore, it will take communication among providers, vendors, clearinghouses, and payers to conduct alternative work. HIMSS believes many providers may already have contingency plans in place, and have identified ways to submit 5010 transactions through vendors by utilizing 4010 transactions and stepping them up to 5010 for compliance.

John Casillas, senior VP of HIMSS business-centered systems, also noted that one of the most important issues addressed in the letter is testing the 835 payment transaction.

"If providers aren't paid because they can't receive the payment files appropriately, they can't process their payments, their cash flow stops, and they will shut down," Casillas said in an interview.

On January 16, 2009, HHS published two final rules that require providers, health plans, and clearinghouses to adopt updated HIPAA standards. The compliance date to transition from HIPAA Version 4010 to 5010 transaction standards is January 1, 2012, and lays the groundwork for the second HIPAA standard, ICD-10 code sets which has a compliance data of October 1, 2013.

With three months left in the calendar year, HIMSS officials say it would be prudent for providers to begin to reach out to clearinghouses and vendors with the capability to provide 4010 to 5010 translation services that will need to be implemented.

According to Casillas, recent survey results show that the likelihood that all providers will meet full compliance may be too much to hope for. "There are, unfortunately, some 33% ... of providers that, based on our last survey in early 2011, do not have a 5010 project. This may have improved, and we'll see in our upcoming survey," Casillas said. "To think that 100% are going to be ready is wishful thinking, and those providers on the ball are already quite clear that they will not be ready by Jan. 1, 2012, due to problems with testing with payers that aren't ready."