HIPAA 5010 caused billing headaches for several healthcare providers when it went into effect in 2012. The law required Medicare, private health insurers, and health providers to comply with new electronic data interchange (EDI) standards established by the Secretary of Health and Human Services and the Accredited Standards Committee.
HIPAA 5010 impacted several claims, payment, and remittance processes, and unfortunately, not all payers, vendors, and service providers were adequately prepared for the transition to this new transaction standard when it went live. Many health systems, hospitals, and doctors’ offices found themselves overwhelmed by the changes and their effect on the systems they had in place. The University of Maryland Upper Chesapeake Health (UMUCH) was one of many health systems that initially struggled to satisfy the increasing demands of HIPAA 5010. However, rather than allowing the transition to put a strain on its revenue, UMUCH chose instead to alter their billing processes in order to diminish their 5010 struggles and help put the provider on a path to improved reporting, claims validation, and overall revenue cycle management.
The University of Maryland Upper Chesapeake Health implemented a new revenue cycle management (RCM) suite to overcome HIPAA 5010 hurdles and received improved overall claims validation in the process.
![]()
HIPAA 5010 caused billing headaches for several healthcare providers when it went into effect in 2012. The law required Medicare, private health insurers, and health providers to comply with new electronic data interchange (EDI) standards established by the Secretary of Health and Human Services and the Accredited Standards Committee.
HIPAA 5010 impacted several claims, payment, and remittance processes, and unfortunately, not all payers, vendors, and service providers were adequately prepared for the transition to this new transaction standard when it went live. Many health systems, hospitals, and doctors’ offices found themselves overwhelmed by the changes and their effect on the systems they had in place. The University of Maryland Upper Chesapeake Health (UMUCH) was one of many health systems that initially struggled to satisfy the increasing demands of HIPAA 5010. However, rather than allowing the transition to put a strain on its revenue, UMUCH chose instead to alter their billing processes in order to diminish their 5010 struggles and help put the provider on a path to improved reporting, claims validation, and overall revenue cycle management.
5010, Reporting Weaknesses Spark RCM Change
UMUCH includes both UM Upper Chesapeake Medical Center in Bel Air and UM Harford Memorial Hospital in Havre de Grace. Combined, these facilities have 274 beds, employ more than 3,000 team members, and send out more than 20,000 claims each month. When HIPAA 5010 went into effect, it didn’t take long for the provider to realize that something was amiss with its existing revenue cycle processes.
“During the 5010 transition, we had hundreds of thousands of dollars of claims on hold,” says Debbie Cyphers, director of patient accounting at UMUCH. “We discovered that these payment delays were due to the fact that many attributes of our existing billing and claims management processes had not been properly tested for the new 5010 transaction standard.”
Moreover, UMUCH recognized the need for more comprehensive reporting capabilities in order to get a true picture of where it stood financially. According to Cyphers, the billing team was pulling basic claim data from each of the hospital systems (both inpatient and outpatient) and then manually comparing data from each of these spreadsheets to gain insight into key revenue cycle benchmarks (e.g., claims validation rate by insurer, clean/unclean claims percentages, total dollars outstanding, etc.). The organization’s manual processes were simply not sufficient; they soon realized the need for a more automated approach to reporting.
Applying Enterprise RCM Capabilities Downstream
The HIPAA 5010-related and financial reporting difficulties UMUCH experienced led the provider to investigate other resources. One of UMUCH’s other partners suggested that The SSI Group, Inc. (SSI), a vendor that specializes in healthcare claims management technology, EDI platforms, and networking, might be able to assist the facility during the 5010 transition.
Cyphers said she wouldn’t have originally considered SSI because they had been known more for catering to large health systems. UMUCH included SSI in a previous vendor evaluation, but ultimately determined that the pricing structure was not feasible for their facility. However, upon a future assessment, Cyphers was pleased to discover that SSI is flexible with its pricing structure and its solution suite, enabling it to address the needs of midsize providers. As a result, she included SSI in her consideration process, and the vendor ultimately worked with her team to develop a customized solution that met UMUCH’s specific billing needs and budget.
![]()
UMUCH’s new solution consists of SSI’s RCM solution, ClaimSmart Suite, ClickON E-VeriSmart eligibility service, and ClickON Claims Status Module. ClaimSmart Suite is a cloud-based software platform that unifies SSI’s EDI offerings into an integrated solution. E-VeriSmart is a service for checking patient insurance coverage, medical necessity, address verification, and service review at any point in the revenue cycle. Finally, the Claims Status Module is a follow-up tool for Medicare and other payers. It allows users to review claims status updates, make real-time corrections to Medicare Common Working Files, and track claims to payers that provide the ANSI (American National Standards Institute) 276 and 277 claims status transactions.
Like most providers that overhaul a software system, there was an initial adjustment period for UMUCH where team members strived to get comfortable using the new software interfaces. Fortunately, managing this transition was relatively easy for UMUCH, largely due to the way the provider structures its accounting team.
“Unlike many hospitals that combine billing and claims follow- up roles, we separate these responsibilities at UMUCH,” says Cyphers. “Our patient account follow-up team is not involved in the billing operations; instead, their function is to resolve outstanding issues with the insurance companies. As a result, we have just two people on our team dedicated to billing. It didn’t take much effort to get these two team members up to speed on the software.”
New RCM Suite Improves Overall Claims Validation
Upon implementation of the RCM suite from The SSI Group, UMUCH experienced improved HIPAA 5010 compliance almost immediately. This was attributed in part to the fact that SSI’s EDI offerings were in line with many of the new 5010 requirements. The SSI solution also provides a platform that allows UMUCH to continually optimize its overall claims performance. For example, claims are identified as “error claims” if they contain incomplete or incorrect information (e.g., a digit missing from a social security number, a suffix missing from a last name, an incorrect CPT [current procedural terminology] code, etc.). In these instances, a team member must manually edit the claims and resubmit them. Many of these edits are specific requirements of state payers. Rather than having to continually address the same edits, UMUCH is able to submit many of the edits to SSI when they encounter them. SSI then adds these edit rules to their software so UMUCH is alerted to missing information on the front end of the process. These efforts have helped to continually improve UMUCH’s overall claims validation rates, which has been instrumental in increasing the provider’s cash flow and revenue.
![]()
UMUCH has been able to accurately assess the claims validation improvements, because SSI’s RCM solution allows the provider to automatically run reports that enable them to view and compare claims validation rates, clean/error claims rates, total outstanding dollars, and more without manual intervention. These reports help UMUCH isolate and address key claims problems, removing many roadblocks to timely payment.
“Reports are paramount to us and should be for other facilities interested in gaining visibility into their revenue cycle,” says Cyphers. “SSI’s reports are an integral part of our processes, as they not only provide insight into the accuracy of our billing practices, but they also provide us with an opportunity to identify problem areas that require attention to resolve.”
HIPAA 5010 caused billing headaches for several healthcare providers when it went into effect in 2012. The law required Medicare, private health insurers, and health providers to comply with new electronic data interchange (EDI) standards established by the Secretary of Health and Human Services and the Accredited Standards Committee.
UMUCH’s new solution consists of SSI’s RCM solution, ClaimSmart Suite, ClickON E-VeriSmart eligibility service, and ClickON Claims Status Module. ClaimSmart Suite is a cloud-based software platform that unifies SSI’s EDI offerings into an integrated solution. E-VeriSmart is a service for checking patient insurance coverage, medical necessity, address verification, and service review at any point in the revenue cycle. Finally, the Claims Status Module is a follow-up tool for Medicare and other payers. It allows users to review claims status updates, make real-time corrections to Medicare Common Working Files, and track claims to payers that provide the ANSI (American National Standards Institute) 276 and 277 claims status transactions.
UMUCH has been able to accurately assess the claims validation improvements, because SSI’s RCM solution allows the provider to automatically run reports that enable them to view and compare claims validation rates, clean/error claims rates, total outstanding dollars, and more without manual intervention. These reports help UMUCH isolate and address key claims problems, removing many roadblocks to timely payment.
