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Payers are on track for the implementation of ICD-10 and do not anticipate problems with processing payments — at least according to Ian Bonnet, vice president leading the ICD-10 rollout at health insurer Wellpoint.
Bonnet added that the same cannot be said for providers. Some payers that are ready, and large providers where they can, are helping small healthcare providers prepare for the broad change to avoid obstacles in payment processing when ICD-10 is required. Such collaborations will supply the “tipping point,” he said at a June 28 healthcare payments conference.
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The conversion to ICD-10 will incorporate many more codes that will enable specific diagnoses and treatment procedure details on claims to produce more accurate payments and fewer reviews and denials.
After Oct. 1, 2013, providers cannot submit claims using ICD-9 coding and expect to be paid.
“We don’t want to mispay providers, Bonnet said. "We are collaborating with physicians and re-coding with them."
With ICD-10, when a claim comes in the door, the appropriate business rules and edits are applied. “We actually see fewer clinical triggers for review with ICD-10,” he added.
For the provider, there is more opportunity than barriers and risks in implementing ICD-10, he said. Over the long term, the system and process renovation activities are less expensive than a provider trying to insulate themselves from the change and paying someone to transform the data on their claims from ICD-9 to 10, which can result in over and under payments.
“Learn the language and become fluent in ICD-10,” Bonnet advised. Providers will also be using the data for quality reporting and business purposes.
He also suggested that providers establish reference maps from ICD-9 to ICD-10 and an accompanying database; focus on the areas of the provider organization where it is most important operationally and technically; identify high-volume partners, especially transaction data trading partners, and model together what coding patterns and transaction results will look like.
Among providers, it’s a struggle to convince hospital leadership that ICD-10 is not just an IT project, but needs to be done in a multi-disciplinary team because it affects all the systems throughout the enterprise, said Lori Sickelbaugh, patient business services director at Lexington Medical Center in central North Carolina, part of Wake Forest Baptist Health.
She recommended not only an audit done by an internal group to assure compliance but also one by an external organization for certainty.
The exactness of ICD-10 affects provider payments from the time a patient walks through the provider’s door by helping to determine a patient’s eligibility and insurance verification. Under the previous coding a service may have been covered, but the specificity with ICD-10 may highlight carve-outs that the insurer won’t pay.
The increase in code volume and complexity to convert to ICD-10 requires that coders get education and training, particularly because the verbiage changes and there is additional detail.
“We’ve been sending staff to ICD-10 resource classes, but the time is not now to get them fully trained because we don’t know if coders will still be there,” she said. “Coders, like physicians, may think it’s too much to go through the large transition and retire. Coders average 54 years old,” she added.
Physicians should also be part of the ICD-10 readiness team to get their cooperation. They, too, will have to improve their documentation, she said.
Readiness for ICD-10 translates to smooth cash flow for reimbursements. Small providers, who may not have technology or budget resources to be as prepared, should apply strategies to cover themselves in the event of payment delays, such as cash flow management and establishing a working capital line of credit with banks or other financial institutions, said John Casillas, senior vice president for business centered systems at the Health Information Management and Systems Security Society (HIMSS).
He also suggested that small and independent practices build a cash reserve of at least six months, despite the fact that they already operate on very slim margins.