Non-federal health  insurers also lose billions annually to fraud, waste and abuse (FWA). Various estimates suggest that between four and ten percent of all health insurance claims  contain FWA. In converting to ICD-10, payers’ claims adjusters, special investigations units  and others evaluating medical claims face  daunting challenges. Payers are concerned that FWA  claims referrals will increase in the near term post-October 1,  primarily because of  increased errors due to both provider and payer confusion and increased customer service inquiries. There will be a critical need for accuracy in billing, where the increased potential for errors will only underscore the requirement for advance training of all billing and related revenue cycle staff — not just coders.According to a University of Illinois research report in the May 2015 American Journal of Emergency Medicine “ICD-9-CM to ICD-10-CM transition is not straightforward and contains hidden mapping and planning challenges that may have not been accounted for even at this late stage of the sprint toward ICD-10-CM implementation….These challenges, if not addressed, may carry significant cost and workflow issues that will be shared by providers and payers alike.”

Why Payers Are More Concerned Than Ever About ICD-10

Therefore, it comes as no surprise that over three quarters of the 205 payers that participated in WEDI’s February 2015 ICD-10 survey stated that they had completed software upgrades, internal business process design and development, and were well into testing their systems. Of the three healthcare industry groups surveyed — providers, vendors and payers — only payers had made substantial progress in their ICD-10 conversion efforts since last year. Many providers, in particular physician practices and smaller hospitals and, are substantially behind the curve in achieving readiness. Many have done little to implement ICD-10.The strong presence of payers at the WEDI conference was significant; their representatives came with a purpose. Sessions that payers led or participated in were strongly focused on increasing a sense of urgency within providers and vendors regarding  ICD-10 compliance. Payers’ preoccupation, not surprisingly, was accurate and timely billing and claims payment, and the many process changes and testing activities necessary to ensure these outcomes by October 1.It was gratifying to see that the posture of payer representatives at the WEDI meeting was optimistic and supportive. Notably, Dennis Winkler of Blue Cross Blue Shield of Michigan, went out of his way to introduce his session on “ICD-10: the Final Push” by emphasizing that: “ICD-10 has provided our industry with a lesson to learn….Next mandate, we must work together.” He discussed various ways in which his organization and other payers are trying to provide direct assistance to providers. While this admirable idea of ICD-10 collaboration continued to be a theme  throughout the conference, the concept may be a case of “too little too late.”

How Payers are Helping

• Payer-sponsored “Open Forum” webinars, intended to provide on-going support through October 1 are available. One example is “Michigan Mondays” held every third Monday, and sponsored by The Payers Collaboration, consisting of Blue Cross Blue Shield of Michigan, Humana, United HealthCare, Priority Health and Health Alliance Plan. A similar program “Florida Fridays,” is sponsored by Florida Blue, and conducted every third Friday. Such programs often include access to previous webinars, as well as tool kits and other resources. Providers should check with their payers to learn about such programs. Incidentally, it often is not necessary to have a relationship with  payers to join in on their webinar programs.
• Testing is still being offered by state payers and private  insurance companies, including the Blues. However, time is running out. For example, providers have the opportunity to partner with MaineCare in pilot testing. Pilot testing began on May 11, 2015 and will continue over several weeks, with the likelihood that it will end in late July. Some payers may continue testing into August, but providers that have not investigated their testing options should do so quickly.
• Some payers offer access to experts, who will provide custom educational sessions to hospital organizations. Again, timing is becoming a problem, so providers should have a conversation with their primary payers as soon as possible.
• Payers are already setting up ICD-10 hotlines to help providers avoid long waits regarding related claims,  bills and authorizations.
• Payers and providers are out in force at regional and national healthcare meetings to exchange intelligence and understand underlying issues. Many payers are sharing past and recent testing results. For example, the WEDI conference featured a panel discussion on ICD-10 testing results, which included Aetna, Humana and United Healthcare participation. Providers should contact their payers to receive copies of available test results.
• Payer and providers are trying to understand better how they can work together, now and in the future. The conference also included a two-hour “ICD-10 Think Tank,” in which attendees broke out into discussion groups to analyze and propose potential collaborative solutions to some of the key ICD-10 challenges ahead. The concept was a good one, despite the fact that there was relatively low representation by providers, with vendors and payers more dominant. Still, the interchange was lively and refreshing, focusing more on how the industry should approach such a widespread compliance initiative in the future, rather than on innovative ideas for the limited  time remaining before October 1. One concept stated frequently (and ruefully)  was “incentives..incentives…incentives.” In other words, why weren’t there incentives, a la Meaningful Use, for ICD-10 too?

While payer / provider interaction is only one element of the surge to implement ICD-10 successfully across the industry, it is one of the most important. Providers are likely to find that their payer representatives will be extra helpful over the next several months. Our recommendation: cultivate those relationships!

To learn how Phoenix can help your organization navigate the next four! months to achieve ICD-10 compliance, contact us. We will make sure you are in a telephone conversation with one of our ICD-10 consultants within 24 hours.