4 predictions for HIPAA and ICD-10 in 2013

By Sunny Singh
08:08 AM

Every year around this time, we all start planning for the next 12 months and try to anticipate the challenges and opportunities that will inevitably arise. This year, it’s no different. And given the magnitude of the changes coming to healthcare, it’s more prudent than ever to make a few predictions and prepare accordingly.

As we’ve compared notes with payers, providers and government agencies, traded ideas, and discussed the outcomes of those conversations, a few themes are starting to emerge for 2013:

1. That giant sucking sound — While no one claims ICD-10 will be an easy transition, many have underestimated the time and effort required. The broader impact to processes, policies and system infrastructure goes beyond anything we’ve faced before, and the old testing, staffing and change management models won’t apply. The moment of truth is next year, most likely in early Q3. At that point, many will come to the stark realization that their current plans won’t get them to compliance in time to meet the deadline. We may see a lot of money, staff time and external resources shifted from other healthcare initiatives to ICD-10 late in the year, as everyone scrambles to make up for lost time.

2. ICD-10 planning redux — As mid-2013 hits, many healthcare organizations will realize they didn’t fully scope out and plan for the business impact. The majority of attention thus far has been paid to payment neutrality (which is understandable), but there are other areas of neutrality, too. Member benefit neutrality, operational neutrality, clinical neutrality — all of these must be planned for as well, particularly in terms of testing. As more healthcare organizations come to this realization, they will have to revamp their ICD-10 plans, with the scope increasing dramatically. The issue is whether organizations will have enough time to do all of these areas justice. As with HIPAA 5010, you will see increased attention paid to contingency plans as more organizations realize they won’t meet the final ICD-10 deadline. By the end of the summer, “Plan B” will become a necessary reality for many organizations.

3. Resource wars — Along those same lines, we will see a big resource crunch in late 2013 — and not just for ICD-10 experts. Across the healthcare industry, we simply won’t have enough subject matter, technology and business process re-engineering experts to manage the number of changes. Once the impact of ICD-10 starts to ripple through other systems and integration or troubleshooting efforts ramp up, even vendors, clearing houses, fiscal agents and system integrators will struggle to keep up. Offshoring won’t completely address the situation, and this means healthcare organizations may be pitted against each other in the fight for resources. The scale and complexity of multiple concurrent mandates may overwhelm all but the most sophisticated and well-prepared organizations.

4. Operating rules bark vs. bite — We’re quickly coming up on the January 2013 deadline for the first round of Operating Rules, which cover eligibility and claim status. And by the end of the next year, healthcare payer organizations must attest they are in compliance with both HIPAA and Operating Rules requirements, and document their compliance in a manner which meets government regulations, or face significant penalties. The problem is, the rules around what to document, how to document, and how to address inevitable interpretation issues have yet to be published. It’s going to be incredibly difficult to implement, test and then certify compliance in time to avoid penalties, unless there’s a grace period. We will see increasing clamor for final, published rules and a safe harbor period after the deadline, when fines are not levied. Our prediction is that—just like HIPAA 5010 – HHS will come under tremendous pressure from health plans to provide a contingency period, or non-enforcement period, even if means amending the enabling legislation.

So how can healthcare organizations prepare for what’s likely to be a bumpy year?

First and foremost, take a hard look at existing plans, budgets and resources. Try to anticipate worst-case scenarios and develop contingency plans to address them. Talk to your vendors and make sure they’re doing the same, especially if you rely on them to manage one or more of the processes affected by ICD-10 and other mandates. Next year certainly won’t be a piece of cake, but if you’re in position to address the challenges and take advantage of opportunities, it won’t be a bitter pill to swallow, either.

Sunny Singh is CEO of Edifecs.