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Like most practices and physicians throughout the country, you are not alone.  The root of the problem seems to be the result of the federally mandated transition to HIPAA Version 5010, enacted on January 1, 2012.  As a nation-wide medical billing company, we see all the medical insurance claims that get sent, rejected and processed to a large variety of insurance companies throughout the United States for our clients.  What we started to notice after HIPAA Version 5010 was enacted, was that Medicare, TRICARE, and a select few of local Blue insurance carriers have halted processing medical insurance claims.  When we first started noticing a lack of payment from these insurance carriers, we inquired with the insurance carriers as to where the money was; they returned with little, to no information as to if the claim was on file or not.  We then consulted our clearinghouses about the issue, who then told us the claims were  forwarded to the insurance companies.  Thousands of dollars in unpaid medical insurance claims are just floating in the clouds with little to no information as to why.

On Feburary 1, 2012, Susan Turney, MD, MS, FACP, FACMPE, Medical Group Management Association's president and CEO sent The Honorable Secertary Kathleen Sebelius of the Department of Health and Human Services a letter asking the government to take "immediate action to address the payment disruption issues that have occured as a result to the federally mandated transition to HIPAA Version 5010 electronic transactions on Jan.1".  Ms. Turney goes on to warn, "Should the government not take necessary steps, many practices face significantly delayed revenue, operational difficulties, a reduced ability to treat patients, staff layoffs, or even the prospect of closing their practice".

To read the full letter MGMA sent to HHS, please visit MGMA's website:

So, What can you do?

Make sure your practice is monitoring any increase in claim rejections and denials by reviewing payer or vendor/clearing house reports.  Make sure you understand the requirements of HIPAA Version 5010 that can commonly affect claims:

  • Use NPI Numbers: Social Security and employer identification  numbers are no longer accepted as primary identifiers
  • Billing address Vs. Pay-to address: HIPAA Version 5010 requires a physical address in the billing field.  If a P.O. Box is used for payments, the address should be entered in the pay-to address field
  • Use a nine digit zip code: Five digit zip codes are no longer accepted
  • Drug reporting requirements: HIPAA Version 5010 requires a drug quanity and unit of measurement whenever a National Drug Code is listed on the claim
  • Both primary and secondary claims MUST have a Medicare Secondary Payer indicator if Medicare is the secondary pay

We at Advanced Billing Consultants, Inc. are also strongly recommending that you call and contact your local Congressman/woman and inform them of this dire issue.  You can find them here:  We have also drafted a letter (requires MS Word, click enable editing -- let us know if you'd like another format),, to either help you with talking points with your Congressman/woman or to send on the behalf of the physician, the physician’s employee, and the insured patient.  We recommend you call, instead of email, and have a short conversation to make sure they are aware of how this issue is affecting the healthcare industry and the people of the United States.