Payment Policy Optimization: Blending Analytics with Rules to Prevent Wasteful, Abusive and Fraudulent Healthcare Spending Curtailing the massive drain caused by waste, abuse and fraud in healthcare has never been more impor¬tant. New payment models are on the horizon, including bundled payments, and greater emphasis is being placed on payment for outcomes. Given the magnitude and visibility of the problem, insurers need to avail themselves of advanced and effective means to reduce wasteful, abusive and fraudulent medical spend¬ing in the most efficient way possible. This demands a more holistic approach across the payment continuum, using technologies that not only address issues from multiple angles but also facilitate cross-organization partnership. Read more now.

ICD-10: There's a tool for that

CHICAGO | June 29, 2012

Healthcare organizations seeking an assessment of their exposure to financial risk in relation to ICD-10 compliance have a new online tool at their disposal. The HIMSS ICD-10 Task Force and Jvion, a healthcare compliance technology and services organization, released the ICD-10 Financial Risk Calculator.

"This tool will help providers set priorities for their ICD-10 planning and conversion efforts to improve their reimbursements," said Dwan Thomas Flowers, co-chair of the HIMSS ICD-10 Task Force.

[See also: ICD-10: Challenging road, promising results]

The new interactive resource prompts businesses to answer a short survey.

"By simply answering a short survey, providers receive unique insight into the powerful impacts of ICD-10, steps they can take to address those impacts and ways to augment their accounts receivable even before they complete their conversion to ICD-10," said Juliet Santos, HIMSS senior director of business-centered systems.

For example, after identifying organization type as a physician practice in an ambulatory setting with between 1 and 25 practicing providers, the survey asks questions such as:

[See also: ICD-10 is big, but ‘the sky is not falling’]

  • In what general range were your 2011 revenues?
  • What is your average denial rate?
  • What percentage of your revenue comes from Medicare?
  • What is your largest specialty by revenue?
  • What is your revenue cycle?
  • What is your current daily average claim acceptance rate into your clearinghouse?
  • What percentage of your current credit line(s) are you using to fund operations?
  • Do you have an EMR upgrade of other major system upgrade that is currently under way or planned within the next year?
  • Do you have a process in place to measure reimbursements against contract-negotiated amounts?
  • Who will be assigning diagnosis codes when ICD-10-CM is implemented?

All information entered into the calculator remains anonymous. At the end of the survey, the organization receives individual financial risk ratings across revenue, operational cost and cash flow categories as well as relative risk ratings, which enable comparison of risk ratings within your peer group.

The calculator also generates specific mitigating steps that can be taken to address financial risk exposure and optimize reimbursements.