GOOD NEWS! – As of September 6, 2011, CMS will give physicians a second chance to use an expanded list of exemptions to avoid a pay decrease of 1% in 2012 for not meeting e-prescribing requirements earlier this year.
Q & A
Did I meet the e-prescribing requirements for 2011?
Physicians will not be penalized or won’t need to apply for exemption if:
- Successfully reported prescribing medicine electronically for their patients during eligible services at least 10 times between January 1 and June 30 in 2011
- OR -
- Reported one of the initial hardship exemptions created by CMS: Those working in areas without high-speed Internet access or pharmacies accepting e-prescriptions.
If I did not meet the requirements above, what do I have to do to avoid the 1% penalty for 2012?
Physicians can try to qualify for one of the significant hardship waivers offered by CMS for the electronic prescribing incentive program by November 1st, 2011. The new exemptions are:
- Registered to participate in the Medicare or Medicaid electronic medical record incentive programs and adopted certified EMR technology.
- Been unable to prescribe electronically due to local, state or federal law or regulation.
- Had limited prescribing activity.
- Had insufficient numbers of eligible patient visits during which to report the e-prescribing measure.
Can HealthTec Software help with any of the new exemptions to avoid the 1% penalty next year?
Yes, HealthTec Software can help. We can assist you to apply for the 1st exemption, with registration and adoption of a certified EMR technology. HealthTec Trilogy is a fully certified EMR system.
Does that mean I have to start using your EMR before November 1st or sometime this year?
No, you do not have to actually start utilizing HealthTec Trilogy EMR before November 1st or even this year to meet the 1st exemption. We can explain how.
Where can I find more information, how to apply for the exemption, the link to the registration for the EMR incentives and information on your EMR?
AMA Summary of Changes to Electronic Prescribing (eRx) Incentive Program:
CMS Changes to the Electronic Prescribing (eRx) Incentive Program:
CMS Exemption Waiver Submission site:
CMS EMR Incentives Registration/Attestation site:
HealthTec Software is aware many of you have received notices from payers and different associations to
make sure your practice is prepared for “5010.”
“5010” specifically relates to the new electronic claim format, which will be implemented on January 1,
2012 and the move from ICD-9 to ICD-10 codes, which is scheduled to be implemented on October 1,
The first major step, which is scheduled to occur January 1, 2012, is the change from the current 4010
electronic claim to the 5010 format. The new format includes over 800 new data elements and will be able
to accommodate the new ICD-10 codes. Many of these new data elements though are situational and
will not impact most claims. These changes are being added to address issues that some providers had
submitting the current 4010 format.
We are aware that you are being asked to begin testing the new format and to contact your software
First, HealthTec in conjunction with our clearinghouse partners has been testing for months. Unless you
submit direct to a payer, you DO NOT need to test. If you submit via a clearinghouse, the
clearinghouse is the submitter. We have verified that our partner clearinghouses (HT Claim Services,
ClaimRemedi, Availity, ClaimLogic and Health-e-Web (formerly ET&T)) have tested and are ready for the implementation of
If you are using a NON-supported clearinghouse to submit claim electronically, you will want to contact
the clearinghouse and determine if they can “cross-walk” your current 4010 format to the new 5010
format. HealthTec DOES NOT support direct submission to payers.
Despite the dire warnings about the “5010” deadline, many practices today are still submitting print image
or NSF formats that are translated into the 4010 format upon receipt.
We have tested our current HTPM system and our new Trilogy application with our supported
clearinghouse destinations. If you are on a Support and Update Subscription and use one of our
Supported Clearinghouse Partners and it is determined any updates or patches are required you will
receive these prior to the January 1st implementation deadline.
If you are on an earlier version of software other than HTPM 5b or HealthTec Trilogy and you are not
using a supported destination you may want to consider changing your clearinghouse now. HealthTec
offers a variety of services including a free option. You will also need to update your software to the
5b version or Trilogy.
“ACO” (Accountable Care Organizations)
Healthcare is famous for its three letter acronyms. Over the past 40 years we have been given the HMO, PPO, MSO, and the MCO to just name a few. Today there is new “three letter” name in the market, ACO.
The ACO’s full name is Accountable Care Organization and just as many of its predecessors, it is the latest attempt at creating a business model to “save” healthcare. What are we attempting to save healthcare from, you ask? Most economists agree that healthcare spending is rising so rapidly that soon, most people won’t be able to afford either their insurance premiums or the cost of care. The concept and name was first noted in a conversation between two doctors at the MedPAC meeting in November 2006. As with all the previous models, which have effectively failed, the goal continues to be to contain costs and more effectively manage the dollars being spent in Healthcare. So what is an ACO?
An ACO is a multispecialty network of doctors and a hospital that is either organized as a virtual network or a real network. The real network will generally be defined by ownership of the members by a single entity; the virtual network will have doctors simply contractually tied to an entity for patient care and so as to be to receive payment for services through the network. In the real network, physicians will be employees, whereas in the virtual network the physician will be an independent contractor. The ACO is seen as the principal tool to reduce Medicare spending. ACO member healthcare providers will manage the total cost of care and provide better outcomes. It is purposed that by treating patients within the network providers will generate better outcomes and at a lower cost. The benefit to the healthcare economic model will be achieved by sharing patient information quickly and efficiently across their network, so that the providers can make better decisions that will cost less. Immediate saving should be experienced by improved communication within the network which will eliminate unnecessary visits, redundant testing and excessive healthcare services. The savings will then be shared across members in the form of incentives or bonuses. The ACO will be defined by three essential characteristics.
- The ability to provide, and manage patients through the continuum of care across different institutional settings, including at least ambulatory and inpatient hospital care.
- The capability of prospectively planning budgets and resource needs.
- Sufficient size to support comprehensive, valid and reliable performance measurement. (It is estimated for ACO to function it will require a minimum of 5000 Medicare lives or 15,000 lives covered with private insurance.)
Today, the majority of healthcare providers are paid on a fee-for-service model that permits them to make more money by providing more services. In the ACO model, providers would not be incentivized for more services but instead for generating better outcomes at a lower cost. They would continue to be paid on a fee-for-service model, but would receive incentives and bonuses for limiting expenses and meeting specific quality outcome benchmarks. The focus of care would shift to preventative services and to the management of chronic diseases.
The compensation model again sounds vaguely familiar to the HMO model where providers were incentivized for “managing” the cost of care associated with their patients. With few details available today, it has not been explained how providers will specifically be incentivized by the ACO. The fear will be that providers, who are trained to deliver care, might be encouraged to withhold services or “manage” care for economic reasons that will benefit the ACO but not necessarily the patient. The goal will be to balance economic decisions against successful outcomes. Whether it is true that better patient outcomes will cost less money is still to be proven.
ACO’s are a principal part The Patient Protection and Affordable Care Act that was passed by Congress and signed into law by President Obama in 2010. In the law, ACO’s are seen as a primary tool for attacking the rising cost of Medicare. “The Congressional Budget Office has estimated that ACO’s will save Medicare at least $4.9 billion through 2019. This amount seems relatively insignificant when considering the total cost over the period but it has been suggested that if ACO’s are successful they will expanded to create a more significant impact and savings. The Engelberg Center reported that Medicare currently spends three times more per person in some regions than it does in other regions with no evidence that the additional expense is directly related to better outcomes.
ACO’s are scheduled to begin operations in 2012. In preparation for that Hospitals are actively purchasing medical practices to create their Multi-specialty ACO Networks. In some cases, providers are simply entering into a relationship to participate with the ACO, creating a virtual network. Currently “pilot” programs are running in several areas of the country which includes Atlanta, Southern New Hampshire and Virginia. It is still too early to know if the ACO model will be a long term solution for that can contain healthcare costs and improve the quality of care, but it is certain our latest Healthcare Acronym will be the subject of many discussions and educational programs in Healthcare for years to come.
Who do these changes affect? What is a “4010” and “5010” anyway? Should I care? Well, I would say anyone concerned about cash flow or prescribing electronically should be concerned.
Some roles that should be concerned are Billing Managers, Practice Administrators and Physicians. As far as Physicians go, I’m generally not talking about those of you that are an employee of a large organization. Someone else in the practice is probably taking care of this for you (we sure hope). I’m talking to those that are their own boss; those that have to make the decisions and/or write the check.
Whether you realize it or not, the electronic transactions that today flow into and out of your practice management system, as well as any electronic prescribing you do, is all currently governed by the Accredited Standards Committee X12 Version 4010/4010A1 for health care transactions and the National Council for Prescription Drug Programs (NCPDP) Version 5.1 for pharmacy and supplier transactions. These were set in place by the 1996 Health Insurance Portability and Accountability Act we all know and love as “HIPAA”.
On January 16, 2009, the United States Department of Health and Human Services (HHS) published the new rules to replace the formats that have been in use for the last many years.
These new rules are:
- Version 5010 for health care transactions (replacing Version 4010/4010A1)
- Version D.0 for pharmacy and supplier transactions (replacing NCPDP Version 5.1)
Should I Care?
You should probably only care about these things if they affect you. Problem is, it affects many, many organizations in the health care arena. Of course, if you’re reading this, there is a good chance it does. The change from 4010 to 5010 affects “Covered Entities”, which include:
- Certain Health Care Providers (actually most physician practices across America plus others)
- Health Plans
- Health Care Clearinghouses
The change from NCPDP 5.1 to D.0 affects:
- Anyone dealing with Pharmacy and Supplier Transactions
What type of transactions does it cover? Well, some VERY IMPORTANT ones, such as:
- Claims (read CASH FLOW!)
- Claims status requests and responses (again, read CASH FLOW!)
- Payment to Providers (again, read CASH FLOW!)
- Eligibility requests and responses (don’t want to do work for FREE do you?)
- Referral requests and responses (keep those relationships intact)
- Enrollment and disenrollment in a health plan
- Coordination of Benefits and premium payments (once again, read CASH FLOW)
If you read the list above, you may have noticed the words “CASH FLOW”. I’m not sure about you, but I really like to have cash flow. I hope you’re like me and would like to make any change that is necessary to maintain a positive cash flow.
So, Why The Change?
So why is everyone so big on changing this up? Well, as hard as everyone worked back in the Nineties and leading into the big Y2K at putting a standard in place that would last forever, it didn’t.
What has happened is that there are many situations, as you can imagine, that could not be anticipated and that the current standards just don’t handle very well. As a result, many payers and other organizations that must use these standards “force-fit” situations that aren’t handled well. I can tell you as head of a software company that deals with these transactions all the time, we are constantly taking on the burden of handling these “force-fit” situations to make sure our clients don’t suffer because of them, particularly when it comes to cash flow. In fact, vendors all across America are constantly making adjustments for these (some better than others).
Now that we’ve had several years to look at these situations, the new format will handle more situations in a much better and more standard way. Will the new formats last forever? Of course not! But they should get us through many more years.
The other big deal about the 5010 transactions is that it creates the foundation for ICD-10, which will not go into effect until year 2013. That may seems like a while to you, but anyone that has kids knows two years isn’t that long!
Now What – What Is MY Responsibility?
So, what is MY responsibility in all of this? Well, when it comes down to it, educating yourself on why the change exists and if it affects you is the first step. Of course, by reading this, you are on your way – congratulations!
The other big part of your responsibility is making sure your software properly supports the new transactions. If your software vendor is not communicating with you regarding these changes, it is now time for you to reach out to them to find out what the plan is.
Your responsibility is also to watch for communications from your vendor(s). As a software vendor of EMR, Practice Management and related services, I can tell you that it is many times VERY difficult to get a message through to the decision-makers in a practice. Please make sure your staff watches for and alerts you to vendor communications.
You’ll want to make sure of at least the following:
- Does your vendor know about and is on top of these changes? (If not, look for another vendor – NOW!)
- When will the changes be ready?
- What are the charges to me for the changes to be put in place?
- When the changes are put in place, will there be an interruption to my practice?
- Do I need to plan for staff training related to the changes?
If you hit December 31, 2011 with no solution in place, one of two things has happened – your vendor blew it or you did. Your vendor mislead you (because, of course, you checked things out with them, right?), or you did not do your due diligence and make sure you were covered, or you purposely decided NOT to keep your system up-to-date.
Are There Any Workarounds Other Than Updating My Software?
There are “probably” temporary workarounds to your software not handling the new changes. This would be through a Clearinghouse, which is basically like the post office for your claims. Most systems today send at least a portion of electronic claims through a Clearinghouse. We at HealthTec work with several and have been in contact with many of them.
It looks like many Clearinghouses will be able to, at least for some period of time, do a conversion of the old format to the new. However, there is no guarantee that your system will send them all required information to perform the conversion or for how long they will be willing to maintain a conversion.
Make sure and talk with your software vendor and/or your Clearinghouse regarding this if it looks like you will not, for some reason, have the required changes in place by December 31, 2011. Even if you plan on using a Clearinghouse to make up for deficiencies in your own system, it should be viewed only as a temporary fix.
That’s It, For Now
I hope this has been helpful to some. Please feel free to contact us for further information about our products and services, or just to chat about these changes.
HealthTec Software, Inc.
About HealthTec Software, Inc:
HealthTec Software, Inc. is a national supplier of unique software technology and related services covering all aspects of electronic health records and revenue cycle management. To find out how HealthTec Trilogy can adapt to your workflow, help achieve Meaningful Use of a Certified Electronic Health Record and help keep track of insurance payer behavior, please contact us at:
HealthTec Software, Inc. / 210.545.1010 or 800.821.6054 / www.healthtec-software.com
Distilled from Centers for Medicare & Medicaid Services website (www.cms.gov) as well as numerous conversations with colleagues and other industry professionals.
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