ICD-10 – A New Sheriff in Town – Penalties as well as Benefits

Many white papers and blogs focus on benefits of ICD-10, but would be remiss if we didn’t also point out the punitive measures.  Health plans must file certification statements that they are in compliance with standards and operating rules by December 2013 including documentation, and provide proof of compliance.   In addition payers will have to provide documentation of proof of end to end to testing with providers.

These Sarbanes-Oxley like measures certainly should get your executive team’s attention if the benefits do not.


The laws have already been enacted. Organizations who do not comply may be subject to a fine of $1.00 per covered life per day if they do not meet the certification requirements.  These penalties double if inaccurate or incomplete information has been provided in the compliance documentation.   This means that a relatively small health plan with 100,000 members could be subject to a $2 million fine, per year.

See ICD-10 Assessments here.

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. He leads a team that provides Cybersecurity best practices for healthcare clients, ICD-10 Consulting, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, Insurance Fraud, payor-provider disputes, and consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been quoted in the Wall Street Journal, New York Times, and National Public Radio.

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