Published On: Thu, May 21st, 2015

ICD-10 anxiety: Third-party billers say neither tech nor clients are ready

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More warning signals are visible on the healthcare industry’s readiness for the upcoming switch to ICD-10 diagnostic and procedure codes, this time from a key revenue-cycle-management sector.

According to a recent survey by the Healthcare Billing & Management Association, a lack of preparedness by the billers’ clients, predominately hospital- and office-based physicians, continues to be a significant barrier.

Population Health definedPopulation health refers to improving the outcomes of cohorts of an entire human population. Key to this is improving access to care in underserved groups, addressing inequities and addressing social determinants such as environmental and economic factors that could adversely impact health. Improving population health is a key prong of the Triple Aim developed by the Institute for Healthcare Improvement, alongside improving individual quality and patient experience and reducing the per capita cost of care.

Is it the emergence of care management platforms; the transition to value-based care; reduced readmissions; the  “affecting change”, such as banning smoking in many U.S. cities; the consumerization and hybridization of care delivery? All of the above? 

The industry has yet to define the term. In the meantime, providers and payers must overcome several challenges before population health becomes common practice.

Here are five big hurdles along the way:

  • Lack of compliance by clinicians
    While many leading health networks have instituted evidence-based pathways, protocols and decisions trees outlining how they want doctors and nurses to treat patients, that actually getting those clinicians to comply with those in the real world remains a challenge.
  • Too little clinical care coordination for patients
    Despite the numerous and various technologies coming to market, poor adherence continues, leading to large-scale overutilization of the system.

Lag in testing

A majority of billers have not conducted basic, “internal testing” of the ICD-10 handling capabilities of their systems. Just 16% have conducted gold standard, external “end-to-end” testing—in which a claim is sent, approved or rejected, and an explanation of what happened, called an electronic remittance advice, is returned. Nearly half (49%) support delaying the ICD-10 start date.

From a biller’s perspective, ICD-10 preparedness needs to be viewed in terms of variable levels of readiness of a chain of actors in the claims-handling process, according to Michelle Durner, president of Applied Medical Systems of Durham, N.C., an HBMA member that participated in the survey. Some providers are still struggling, but “once the chart gets to our office, I become more optimistic from that point on,” Durner said.

Her firm’s technology vendor, Healthpac, has been ICD-10-enabled for some time, she said. “I would assume that it is smaller companies that aren’t ready,” she said.

“The larger payers, Medicare and Blue Cross Blue Shield, they’ll be there,” Durner added. “With some of the state Medicaid agencies, I’m maybe not quite as confident. And with the smaller payers, I just don’t know. You just cross your fingers and hope. Just like with 5010, I don’t think it will come off without a hitch.”

A precursor to the ICD-10 expansion, the 2012 switch to Version 5010 billing communications standards went badly, causing significant payment reductions and forcing the CMS to push back enforcement of HIPAA penalties for noncompliance.

HBMA members need to do a lot more “end-to-end” testing between now and the Oct. 1 switch over, said Andre Williams, executive director of the association. “Some of them have done it, but we need more testing before we go live and time is running out.”

The billers’ survey results are similar to those found recently by the Workgroup for Electronic Data Interchange, which polled more than 1,100 providers, payers and vendors. WEDI found that only 37% of survey respondents had ICD-10-ready software available.

Fear of delays

WEDI members were even more spooked than the billers by the specter of the feds delaying ICD-10 once again as more than half cited “uncertainty around further delays” as a primary obstacle to implementation.

“Folks aren’t willing to invest the time and energy if it’s going to be delayed again,” Williams said. That’s translated into watching and waiting by billers as well as other healthcare industry players, he said.

Although some billing association members are midsize companies with 300 or more employees and nationwide operations, the majority are small businesses operating in one to 10 states.

Nearly half (47%) of the 88 billing companies whose officers were surveyed had 24 or fewer employees. Durner’s company, which she purchased seven years ago from her mother, has 17 employees and does business in 13 states.

Medical billers are “at the epicenter of the claims submission process,” according to Robert Tennant, senior policy adviser to the Medical Group Management Association, whose members, office-based physician practices, are HBMA members’ customers. As such, they are canaries in the coal mine for ICD-10 problems, and their survey shows, “These folks are clearly not ready,” Tennant said.

Tennant did find some good news in the survey data: About three-fourths of the billing companies have IT systems that will support both ICD-10 and the current ICD-9 code sets, their representatives report.

One possible workaround being suggested—if substantial numbers of healthcare organizations fail to achieve ICD-10 compliance—is to process claims in a “dual-coding” mode for a time until all the stragglers catch up. That means some providers will still be able to submit claims in ICD-9, with billers helping with the conversions from ICD-9 to ICD-10.

But the dearth of end-to-end testing is “very disconcerting,” Tennant said. “What that tells you—and it’s indicative of the broader industry, including payers and providers—is that we’re going into Oct. 1 flying blind.”

Wayne Becker

Wayne Becker is a visionary, dynamic nursing leader with over 20 years of clinical expertise and 10+ years of management experience. Experienced in multiple organizational settings from individual community hospitals to tertiary, academic facilities. Demonstrated excellence in quality critical care and emergency care and fiscal accountability. Change agent who leads process improvement initiatives as well as managed staff through significant technology upgrades. Developed mentoring relationships that prepared staff at all levels for advanced professional opportunities.

Specialties: Trauma Nursing, Critical Care Nursing, Emergency Nursing, and pre-hospital Emergency patient care. Utilization Management and leadership experience in for-profit and non-profit environments. Union and non-union leadership experience. Multiple EDIS and CPOE platforms.

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