ICD-10 Impacts Insurance Verification for Payors and Providers if Codes are Included in Workflow

ICD-10 transition has several impacts that many health plans and health care providers will not consider, unless they are doing a comprehensive assessment of all systems and processes.  If ICD-9 diagnosis coding (ICD-9 CM) and ICD-9 procedure codes are included in the workflow.

Systems that capture ICD-9 codes  in the workflow will need to be revised.  Payor specific EDI systems  also need to be reviewed and most likely remediated.  Supervisors and other staff that work on the Insurance Verification process will need to be re-trained for ICD-10 CM diagnosis coding and ICD-10 PCS procedure codes for inpatient care.  Standard operating procedures need to be re-examined.  Provider scheduling will also need to be reviewed for ICD-10 process changes.  Payor – provider testing will be required to ensure that the remediated systems and processes are working.

Similarly, the EDI transactions supporting this workflow are relevant.  The eligibility / benefits inquiry and response transactions (HIPAA x12 270 and 271) should be comprehended in this systems, process remediation and subsequent testing.

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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