In Sync With ICD-10
By Selena Chavis
For The Record
Vol. 25 No. 9 P. 18
In the race to prepare for the new codes, will providers and payers be able to successfully cross the finish line together?
It’s been said that a chain is only as strong as its weakest link. As the timeline for the health care industry’s mammoth ICD-10 implementation marches forward, industry professionals are becoming increasingly aware that if all stakeholders are not ready for the October 1, 2014, deadline, calamity could ensue.
“Everyone is wondering about everyone else. That’s why communication is so important,” says Kathy DeVault, RHIA, CCS, CCS-P, director of HIM practice excellence at AHIMA. “Payers are worried about providers, and providers are worried about payers”—and for good reason.
Industry professionals got a glimpse of the potential fallout that could ensue when a glitch in the mental health medical code system wreaked havoc on patient care and reimbursement schedules. An NBC News story detailed how the first major overhaul of the CPT code system since 1998 produced systemwide delays and outright payment denials. Is that the sort of mayhem in store for health care organizations next October?
Steven Benjamin, UnitedHealthcare’s program director for ICD-10, believes most medium to large organizations are pretty well on track and have worked to stay in front of the ICD-10 road map but cautions that the industry likely won’t wait for others to catch up. “If we end up in a situation where providers are not ready and are submitting ICD-9 codes, there is going to be a rude awakening,” he says.
New research findings suggest that industry progress has not kept up with early expectations for readiness. A February survey on ICD-10 preparations from the Workgroup for Electronic Data Interchange revealed that nearly one-half of the 109 payers polled expect to start external testing by the end of 2013, while a survey conducted a year earlier found that 100% of health plans expected to begin testing in 2013. Of the 778 providers surveyed this year, one-half had not set a date for completing an impact assessment, making business changes, or commencing with testing.
Stanley Nachimson, principal of HIT consulting firm Nachimson Advisors, believes that payers in general are a little ahead of providers. “Any hospital that is just starting now will have to work intensively to catch up,” he says, adding that payers seem to be making a concerted effort to be ready. “One of the concerns many providers have is that they haven’t yet seen what the real impact will be in terms of payment.”
The big question for both sides is: Where should we be at this stage? While several timelines have been suggested by the Centers for Medicare & Medicaid Services (CMS) and various industry trade groups, Nachimson notes that the delay in the official start date may have caused some confusion. “CMS recently indicated that organizations should be in their internal testing phase [as of April],” he says. “By October, they should be moving toward external testing.”
Alongside internal testing strategies, DeVault notes that payers should be actively educating their staff. “Do they have coders on staff? Have they started educating their coders?” she questions. “If they haven’t done an assessment of education needs, they need to do that.”
Benjamin believes that most national payers will complete their internal testing this year and begin external testing with business partners in early 2014. UnitedHealthcare, which will likely begin testing at that time, is presently building a list of clients to partner with during the testing phase. “We have tried to carve out those partners who have strong relationships with us, some where we have done testing in the past where systems and infrastructure may already exist,” he says. “We will not be able to do in-depth testing with every partner who requests it.”
Because of the significant financial implications of the ICD-10 conversion, Nachimson says external testing is a crucial component of any preparation strategy. “Hospitals should be in touch with those payers who account for their greatest revenue,” he says. “If a payer won’t be ready until August 2014, that won’t leave enough time for testing.”
In an effort to establish baseline analysis, UnitedHealthcare has attempted some early collaborations with providers to process historical claims under the new system. Benjamin says the response from providers has been somewhat disappointing. “Without real-life claims, we can only guess about the impact,” he says, adding that UnitedHealthcare has not received the cooperation it expected from providers who have been negligent in sending claims. “Everybody realizes it should happen, but realistically resources are short all around. It just hasn’t happened on the scale it should.”
Monitoring Payer Progress
If payer and provider strategies are not aligned, the consequences will damage provider revenue cycles, DeVault says, pointing out that providers need to emphasize and support regular communication with their payers. “Across the board, providers have this fear that payers won’t be ready or payers won’t get it with ICD-10,” she says. “They feel this will slow down the claims process or that the reimbursement system is going to come to a screeching halt.”
DeVault believes there will be some inevitable early glitches, which makes regular communication imperative for identifying potential issues before they occur. It also means having the right people at the table. “Conversations should include someone in coding and patient financial services,” she says.
Be as specific as possible when communicating with payers, DeVault says, noting that “if you ask a vague question, you get a vague answer.” She suggests providers ask payers the following questions:
• Is your internal testing under way?
• If not, when will you begin external testing?
• What kind of data do you need from us?
• What kind of edits are you building into the system?
• Can we review the edits?
While providers have distinct concerns about payer progress, many payers have similar worries, especially when it comes to how to manage providers that don’t meet the deadline. Benjamin notes that some payers are considering workarounds in which mapping systems offer backward and forward conversions between ICD-9 and ICD-10. “I’m personally not a fan of the mapping scenario, but it has been thrown out there,” he says, adding that some clearinghouses also are looking to offer mapping solutions to providers. “That creates some higher-risk scenarios. Too many players are involved in the process.”
Collaborations Are Key
Because of the complexities and far-reaching ramifications of the ICD-10 conversion, many health care professionals are looking to industry partnerships for support and answers. According to Nachimson, many of these efforts are already under way in states such as California, Massachusetts, Minnesota, and Idaho. “Those collaborations are key to successful implementation,” he says. “Payers and providers need to be communicating throughout the entire process. We need more cooperation and collaboration with [ICD-10] than with other previous initiatives where readiness could be completed independently then brought together in the end.”
For example, the newly formed California ICD-10 Collaborative is designed to help providers, insurers, and vendors share best practices and collaborate on code-set testing, lowering risks, and reducing implementation costs. As of March, 11 health care organizations had joined the group.
On the other side of the country, the Massachusetts Health Data Consortium has created a similar collaboration to establish clear communication channels among all stakeholders and ease coordination.
Benjamin notes that these types of projects lessen the burden on individual providers and payers already faced with serious resource constraints. In an effort to create a repository of information for providers, UnitedHealthcare surveyed its constituents early in the ICD-10 process to determine information needs. Thanks to the complexities of the ICD-10 transition, the undertaking became extensive. “Every completed survey is like a snowflake. We keep trying to come up with answers to new questions,” Benjamin says. “There are a lot of industry workgroups working collaboratively to make information more available. I would suggest relying heavily on them.”
Benjamin says UnitedHealthcare has been working with several regional collaborations to create a “common” repository of information so organizations aren’t hitting up each other individually. “It would be nice to see that happen throughout the nation,” he says.
Payers and providers agree that all stakeholders should be prepared for some complications, especially in the early stages of the conversion. “It would be unrealistic for us not to expect some problems with a change this significant,” Benjamin says.
DeVault agrees, adding that “denials are going to happen with the new system and there’s going to be a period of adjustment.”
To be fully prepared for all possibilities, health care organizations need to develop strategies to address shortfalls and delays, according to Nachimson. A foundational tactic for any organization is to build a cash reserve or establish a line of credit for use in the case of a disruption.
Contract negotiations with various payers also should be a consideration. Nachimson suggests health care organizations discuss options for interim payments based on a percentage of payments from previous years. “For example, let’s agree that you will send a payment of one-twelfth the amount we received last year until we figure it out,” he suggests as a possible negotiation point in case of denial disputes.
While it will require some up-front cost, Nachimson believes payers need to bring in additional staff for a smoother conversion. “A lot of payers learned in the 5010 implementation that they will be getting a lot of calls,” he notes.
In anticipation of potential glitches, Benjamin says payers are indeed investigating staffing needs. While UnitedHealthcare had hoped to remain operationally neutral, he believes that for the short term, additional staffing will be inevitable. “I don’t think we are going to get around it,” he says, pointing out that from just a customer service standpoint, there will need to be more hands on deck to field calls and questions.
DeVault says additional staffing needs to be a consideration for payers to make sure they are adequately prepared. “There is no such thing as too much preparation,” she says.
— Selena Chavis is a Florida-based freelance journalist whose writing appears regularly in various trade and consumer publications covering everything from corporate and managerial topics to health care and travel.
National Program Offers Testing Resources
In an effort to prepare for ICD-10 testing and share the best practices of early adopters, HIMSS is partnering with the Workgroup for Electronic Data Interchange (WEDI) to implement the ICD-10 National Pilot Program. The industrywide collaborative will develop a standard set of testing scenarios and identify an “asynchronous” model for small and large organizations to conduct ICD-10 testing, a critical component of readiness.
“Health plans have a lot of claims data in terms of taking a look at the potential impact of ICD-10,” says Stanley Nachimson, principal of Nachimson Advisors. “Hospitals should be looking at that data as well.”
The program’s goal is to offer health care organizations a means to begin testing early to identify potential issues well in advance of the compliance date of October 1, 2014. According to HIMSS, the pilot program will offer three opportunities for organizations ready to test based on the availability of financial resources. The schedule is as follows:
• Phase 1: April 1 to July 31, 2013
• Phase 2: August 1 to February 28, 2014
• Phase 3: March 1 to August 31, 2014
Organizations may be charged a nominal fee for phase 2 and phase 3 testing.
The program is designed to meet the following goals:
• Identify standard testing scenarios that can be utilized by the health care industry for free.
• Provide resources and guidance to providers during the implementation phase through the development of a virtual regional solution center.
• Publish incremental data on testing outcomes, best practices, and new findings in the ICD-10 PlayBook, a free resource.
• Build collaboration and mutual trust through the sharing of ideas and best practices.
• Enhance the efficiency of the testing process, thus reducing the cost of testing trial and error for most organizations.
More information can be found at http://www.himss.org/library/icd-10/national-pilot-program?navItemNumber=13477.