Impact Analysis

The individual segments across the full spectrum of health care that must comply with these new regulations are impacted by it are

Physician Practice

• Need to upgrade practice management and EDI systems to comply with the new version and standards
• Need to work with their Claims clearing houses to ensure compliance

Alternate Site Providers

• Rehabilitation clinics, as well as other in-patient and out patient facilities need to upgrade the systems as Physician practices.
• Need to work with their Claims clearing houses to ensure compliance

Hospitals

• Need to upgrade billing, EDI systems and to work with their claims clearing houses

Payers (Insurance Companies)

• Need to work with all trading partners
  • Claims Clearing house
  • Direct Providers sending claims
  • Employers for enrollment and premium payments
• Medicare and Medicaid systems upgrade to compliance with new standards
• Claims EDI adjudication system
• Data warehouse system additions for new fields,
• Business Intelligence to add remove 5010 changes

Clearing Houses & Repricing Companies

• Need to upgrade EDI infrastructure includes
• Mapping, Validation, editing, translation systems and etc.
• Most receive non-compliant documents from providers, Clearinghouses need to convert them into 5010 HIPAA compliant version.
• Change to 5010 add additional layer of converting from 4010 to 5010

5010 impact

HIPAA requires to adopt standards that covered entities required to use in electronically conducting certain health care administrative transactions, such as claims, remittance, eligibility, and claims status requests and responses. Covered entities include health plans, health care clearinghouses, and health care providers.

The current transaction standard is X12 version 4010A1 for health care claims, remittance advice, eligibility, claims status, referrals, and NCPDP version 3.0 for pharmacy claims. The Centers for Medicare & Medicaid Services (CMS) is proposing that the industry upgrade to X12 version 5010.

5010 version as improvement in significant transaction and also added, improved, business functions and content. More clarity in provider loops and support for ICD-10 was added in 5010.It also Clarifies National Provider Identifier (NPI) instructions in 5010.

The major entities that would be impacted by the implementation of 5010: Physician practice, Alternate site providers, Hospitals, Payers (Insurance Companies), Clearinghouses and Reprising Companies.

HIPAA 5010 comes with major changes such as: Structural changes, Front matter changes, Technical improvements, Data content changes.

ICD-10 impact

International Classification of Diseases (ICD)-10 is the next version of ICD-9 has the ability to reflect advancements in healthcare and the related technologies. ICD-10 also supports the same business processes as they were in ICD-9 but there exists vast differences in capabilities. ICD-10 containing new, updated code sets enables it to carry and analyze the much more information and thus become capable of handling and supporting new and emerging diseases. Due to lack of complete support for its diagnosis and procedure codes from 4010, industry came up with 5010 by influencing payers operations enormously. ICD-10 brings quality and flexibleness in coding and also helps payers to captivate better information.

ICD-10 comes with improved functional areas such as: Enrollment, Underwriting, Policy Administration, Customer support, Health management, Claims processing.

Miracle Impact Mitigation Strategy

Miracle Software Systems is a global systems integrator specialized in providing HealthCare specific solutions in a customized way by leveraging market leading technologies and tools. We are highly qualified and having certified expertise to assist you in transition from existing standard to meet the HIPAA regulations at low cost.

Miraclesoft Impact on HIPAA 5010 upgrade service offerings evaluates your existing 4010 translation system and provides recommendations on how your organization can best support the new 5010 transactions in parallel with the existing 4010 processing. Once support for the older standard ends, the 4010 processing can easily be removed

Miracle Services around HIPAA 5010 and ICD 10 upgrade are

• Gap Analysis for HIPAA 5010 upgrade
• Analysis on Mapping changes required to implement
• Implementing the EDI 5010 changes.
• Implementing the ICD 10 changes.