ICD-10 Claim Date of Service Spans Mandate, Mapping ICD-10 to ICD-9 Auto Adjudication Questions Posted

In the ICD-10 Consortium social network this week, health plans posted questions regarding processing ICD-10 claims that have date of service  periods that span the mandated timeline as well as an outreach to other health plans regarding the pros and cons of receiving an ICD-10 claim, mapping it to an ICD-9 to adjudicate it.  Also, ICD-10 is expected to impact auto adjudication rates for plans.

No World Borders maintains several social media groups that enable payors and providers to discuss ways to overcome challenges, innovate and share best practices including electronic medical records, HIPAA mandates such as ICD-10 and their impacts, Medicare Advantage, and Accountable Care Organizations.

To view these questions, post your own answers or view the answers of other health plans and providers click the links below.

Authorizations that span the compliance date?

I am curious how payers are documenting their requirements for business and/or system changes around Claims and Authorizations. Auths…

Mapping back to ICD-9 from ICD-10

“Hello, any Blue plans out there considering using down mapping, or backward mapping to handle institutional claims? Essentially backward map from I10 to I9 in order to price DRG based claims?”

Note: while we are posting this discussion regarding “down mapping” or “step down” to ICD-9 we do not recommend the approach. Some payors are going to have to do this as an emergency scenario because of time and budget constraints but it introduces other issues – NWB

Auto adjudication rates

How are Blue plans baselining their auto adjudication rate? What tools/products/policies used in order increase Auto adjudication rate?…

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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