Accountable Care, HEDIS Quality Measures and ICD-10

The U.S. Department of Health and Human Services and CMS provided incentives which will improve the top line reimbursements starting 2012, but to realize this benefit, HEDIS Star Quality Rating System dashboards, business intelligence and supporting data integration and aggregation capabilities will need to be in place.   The elimination of data re-keying, manual data entry, and timely access to this information for forecasting purposes will be key.

Health care quality measures will have to be rewritten for ICD-10 coding to identify both the numerator and denominator of measures.

Second, the increased specificity of the ICD-10 codes mean that plans and providers can get and use better information on claims for quality measurement and improvement.

According to CMS, “Invest in Improvement

Health plans should be aware that the 2012 MA reimbursements will be based on the 2011 CMS Five-Star Quality Rating system. Improvement in those areas will increase reimbursement almost immediately. The key is knowing where you are starting, understanding what measures represent the best opportunity for improvement in the Five-Star Quality Rating system, and then focusing resources on making the changes that will lead to the largest improvement in the plan’s overall star rating.”

The ICD-10 Assessment and implementation plan should take this into consideration.

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 and for more about the company.

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