Healthcare Entities can Test 5010 Transaction Compliance CMS National 5010 Testing Week is THIS WEEK!

Healthcare Entities can Test 5010 Transaction Compliance CMS National 5010 Testing Week will be August 22-26, 2011 CMS conducted its first National Testing Day on June 15, 2011 allowing medical practices and other entities upgrading to Version 5010 claim transaction files to submit sample data to test their systems.  In this first such event, 349 entities submitted 974 files with no significant errors.  Of the participants surveyed afterwards, 32% felt ready to process Version 5010 transactions. CMS is following this up with an even bigger National 5010 Testing Week scheduled for August 22-26, 2011.  National 5010 Testing Week will provide entities that are working toward 5010 compatibility an opportunity to test the compliance of their systems with the support of a real-time help desk and access to Medicare Administrative Contractors (MACs) for assistance with problems. Testing is critical because version 5010 is the new version of the X12 standards for HIPAA compliant electronic transfer of health information between providers and Medicare, insurers or other health-related entities.  Full 5010 compliance is required for most entities as of January 1, 2012, the deadline when they must transfer medical information electronically. Register to participate in the National 5010 Testing Week exercise through your MAC.  To ensure that your registration is properly recorded and is not rejected, be prepared to provide the information listed below: Company name Vendor/Submitter ID PTAN NPI Type of submitter (e.g., provider, billing service, clearinghouse or vendor) Street address of submitter City/state and ZIP EDI contact person E-mail address Type of transactions you are going to test (e.g., 837I, 837P, 276/277 or 835) How will you be sending your test file (e.g., Dialup, FTP or NDM) Line of Business (e.g., J1 Part A, J1 Part B, J11 Part A, J11 Part B, J11 HHH or RRB) The Secretary of the Department of Health and Human Services (HHS) adopted version 5010 to replace the current version of the X12 standard for electronic transactions including claims (professional, institutional and dental), claims status requests and responses, payment to providers, eligibility requests and responses, referral requests and responses, enrollment and disenrollment in a health plan, Coordination of Benefits and premium payments.  There are three levels of 5010 compliance.  Level I compliance, required beginning on December 31, 2010, means "that a covered entity can demonstrably create and receive compliant transactions, resulting from the compliance of all design/build activities and internal testing."  Healthcare entities must be testing throughout calendar year 2011, and must schedule testing as early as possible, to ensure sufficient time for corrective actions and re-testing. Level II compliance will be required on December 31, 2010.  Level II means "that a covered entity has completed end-to-end testing with each of its trading partners, and is able to operate in production mode with the new versions of the standards." Level III means full compliance with Version 5010.  The compliance date for Medicare providers and other entities is January 1, 2012.  The Medicaid deadline also is January 1, 2012, except for small health plans that have until January 1, 2013 to come into compliance. The requirement to adopt transaction standards originated from the 1996 Health Insurance Portability and Accountability Act (HIPAA).  The Transactions and Code Sets final rule published on Aug. 17, 2000, adopted standards for the statutorily identified transactions, some of which were modified in a subsequent final rule published on Feb. 20, 2003. On January 16, 2009, HHS published a final rule that replaces the current Version 4010/4010A and NCPDP Version 5.1 with Version 5010 and Version D.0, respectively, and adopted NCPDP Version 3.0 as well.

Appeals Court Finds Insurance Mandate is Unconstitutional

The U.S. Appeals Court for the 11th Circuit, located in Atlanta, decided on Friday, August 12, 2011 that the Affordable Care Act’s requirement for all Americans to buy healthcare insurance is unconstitutional.
 
However, the three-judge panel also reversed a lower Florida court’s decision that the entire law is unconstitutional.
 
Florida Judge Roger Vinson, appointed by Ronald Reagan, had argued that the mandate is so central to the law’s function that the rest of the law is invalid without the mandate. “I must conclude that the individual mandate and the remaining provisions are all inextricably bound together in purpose and must stand or fall as a single unit,” Vinson wrote.  In contrast, the 11th Circuit Appeals Court refused to invalidate the entire law.
 
The Obama administration argued that the insurance mandate falls under the Commerce Clause of the U.S. Constitution, which gives Congress the power to regulate interstate commerce.  Twenty-six states challenged the mandate, arguing that Congress had exceeded its authority by imposing the requirement.  In a jointly-written opinion, Judge Joel Dubina appointed by Republican President George H.W. Bush and Judge Frank Hull appointed by Democrat President Bill Clinton disagreed with the administration’s view.
 
“This economic mandate represents a wholly novel and potentially unbounded assertion of congressional authority: the ability to compel Americans to purchase an expensive health insurance product they have elected not to buy, and to make them re-purchase that insurance product every month for their entire lives,” the two judges stated in the majority opinion.
 
Judge Stanley Marcus, also appointed by Clinton, wrote the dissenting minority opinion.  The majority, he stated, ignored “the undeniable fact that Congress’ commerce power has grown exponentially over the past two centuries and is now generally accepted as having afforded Congress the authority to create rules regulating large areas of our national economy.”
 
The Obama administration stated that it disagrees strongly with the majority ruling and expects that the decision will not stand.
 
The legal status of the individual mandate is expected to be decided by the U.S. Supreme Court.  The 11th Circuit Appeals Court decision contrasts with an earlier one by the 6th Circuit Court in Cincinnati, which upheld the individual insurance mandate as constitutional.  That case has been appealed to the Supreme Court.  The Court of Appeals for the 4th Circuit in Richmond has yet to rule in a separate case brought by the state of Virginia.  A federal judge in Virginia had ruled the mandate unconstitutional, as well

Highmark Blue Cross to Buy West Penn Allegheny Health Insurer Plans to Employ Doctors Rather than Negotiate Fees

Highmark Blue Cross to Buy West Penn Allegheny Health

Insurer Plans to Employ Doctors Rather than Negotiate Fees 

Highmark Blue Cross Blue Shield announced in June that it plans to purchase West Penn Allegheny Health, one of the region’s biggest hospital systems known as the institutional home of the Temple University School of Medicine.  

The acquisition, officers say, provides the insurer an opportunity to replace negotiated fees for services with an employment-based model that pays doctors salaries.  The company seeks higher quality and efficiency through greater control of patient care, which it believes will allow it to shrink unnecessary and duplicate services.  Primary care physicians will coordinate patient care and encourage preventive health practices.

The announcement added hot sauce to an already bitter argument between Highmark and the University of Pittsburgh Medical Center (UPMC), a large integrated hospital network, over rates Highmark pays UPMC hospitals and its physicians for medical care. West Penn Allegheny Health, which Highmark plans to acquire, is UPMC’s largest competitor in the Pittsburgh area.  Current Highmark contracts for most UPMC hospitals expire June 30, 2012.  Negotiations between Highmark and UPMC broke down in March.
 
In mid-July, Highmark filed a lawsuit against UPMC and most of its hospitals claiming that UPMC breached its contract and aired misleading advertisements against Highmark.  Highmark accuses UPMC of seeking excessive rate increases, and UPMC claims that it cannot work with Highmark now that the insurer has announced plans to purchase UPMC rival West Penn Allegheny Health System.

Physicians and others watching the acquisition talk – and the impasse between Highmark and UPMC – fear damage to healthcare in Pennsylvania from a dispute intensified by Highmark’s plans.

What will a merger do to affected physicians, who lose control over how much they may work and earn?   How will this affect patient care?

In the state senate, Pennsylvania’s political leaders are thinking about intervening in the contract standoff.  On July 18 two Republican state senators, Don White and Kim Ward, called for hearings on Highmark and UPMC to determine Pennsylvania’s regulatory role in the conflict.

"I'm not picking a side in this dispute," Ms. Ward said in her statement, "but I am asking them both to get back to their mission of taking care of the people of southwestern Pennsylvania who depend on them for their healthcare."

Mr. White's staff said at least some of the hearings would be held in Pittsburgh.  None have been scheduled as yet.

For now, all observers can do is to watch and wonder – as do we all.