ICD-10 Implementation Train Wreck

Health care providers can help minimize the downside cash flow and revenue impacts of ICD-10 by organizing and planning for contracting with Payers in anticipation the change to ICD-10 in October 2013. 

Health care payers will be designing their reimbursement plans for 141,000 new ICD10 codes.  It will be critical for providers to know their required reimbursement for these new codes before they negotiate with Payers who will certainly try to reduce reimbursement.

In this adversarial healthcare environment, health care providers must be proactive in understanding a strategy to avert potential disasters in their reimbursement system.  With the thin margins that most hospitals already operate on, we believe this will be one of the most important aspects of implementing ICD10.  ICD-10 is not just a new diagnostic system of coding; it is more importantly a new reimbursement system.

Here are just a few more to think about:

  • Management some payers and providers apprently still perceive that a GEM (General Equivalence Map) will provide the magic bullet they need to automatically convert their systems from ICD-9.  Unfortunately, this is not true.  GEMs are icomplete because they are based on going from less detail to more.

  • Recently we talked to a company that felt that if they simply changed the field length in their databases, they would be ready for ICD-10.  Unfortunately this is not the case.

  • If you rely on an out of network repricer, and your vendor uses automated methods based on historical data, they won’t work under ICD-10.  Significant modifications will be required. 
  • Avoiding the ICD-10 implementation train wreck will be easier if your company is doing an assessment of the business, process, system, clinical and IT impacts early in this process.  Conversely, those health insurance firms, hospitals, clinics, physician groups and other entities who are proactive in seeing an ICD-10 assessment as an avenue to improved revenue and cash flow will be better positioned strategically when the market shifts.

    If you do not believe you have these skills in house, look to partner with a consulting team that has the process, people, methods and tools to successfully navigate this new reimbursement system.

    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. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, 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, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA 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 interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See https://www.noworldborders.com/news/ and https://www.noworldborders.com/clients/ for more about the company.

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