Payers outpace providers on ICD-10

By John Andrews
10:03 AM

 When it comes to ICD-10 preparedness, payers are well ahead of providers in the quest to be ready for the new coding format by the Oct. 1, 2013 deadline. That news probably doesn’t come as a shock to anyone involved in the process, but it shows that the claim-filing infrastructure should be ready on the receiving end, coding experts say.

“Large payers are ripping through this – they’re going great guns,” says George Schwend, CEO of Denver-based Health Language Inc. “That makes sense because it’s their business. Smaller payers, however, are still figuring out what to do.”

Given the massive scope of the coding changes, it is readily apparent why healthcare organizations have a lot of “figuring out” in front of them. ICD-10 will greatly multiply the number of codes for claims processing, with diagnosis codes expanding from 14,000 under ICD-9 to 69,000 under ICD-10; and procedure codes growing from 3,000 under ICD-9 to 71,000 under ICD-10.

The contrast in progress between large organizations and smaller ones applies to the provider sector as well. Yet because provider headway is behind the payer community, it typifies the disjointed progress between the two camps, says Kristine Weinberger, senior healthcare business consultant at Seattle-based Edifecs.

“Payers aren’t reaching out to providers on this issue,” she said. “Maybe a few are, but the vast majority of payers aren’t at that step yet.”

All of which begs the question: Is the healthcare industry – including both payers and providers – where it should be on the readiness scale? Consensus among ICD-10 specialists is that nobody is ready at this point, but what happens over the next year will tell the story.

The other big question, of course, is will the Oct. 1, 2013 deadline stick? Acting CMS Administrator Marilyn Tavenner announced on Feb. 14 that CMS would take another look at the timeline. The announcement, welcomed by many, raised a number of questions from those organizations who had already spent time and money to prepare – with the 2013 deadline as goal.

Understandably, providers are further behind because they have to do more heavy lifting. Brad Boyd, vice president of sales and marketing at Woburn, Mass.-based Culbert Health Solutions, points to one of his large physician practice clients who calculated that getting fully prepared for ICD-10 would take approximately 60,000 hours of work.

“That equates to 30 people working full time on ICD-10 for a year,” he said. “The resource intensity of the project is that massive.”

Eric Mueller, president of Seattle-based WPC Services, states matter-of-factly: “The industry isn’t even close to being ready for ICD-10.” While some organizations are doing assessments and gap analysis, these stages represent a movement that is still in its infancy, he said.

A vendor issue?

There are questions circulating about some providers not taking the issue seriously enough, preferring to “let the vendor handle it.” It is a tack that Mueller sees as not only dismissive, but irresponsible.

“You never ask a life insurance salesman if you need life insurance,” he said. “So if you ask a software vendor if you need more software, you know what the standard answer will be.”

Boyd adds that providers relying on vendors “don’t have a clue,” and that they may not understand the true ramifications of not being ready by the Oct. 1, 2013 deadline.

“ICD-10 can bankrupt you,” he said. “If you can’t bill or collect, your organization will go under.”

Most providers – especially the larger ones, are engaged in ICD-10 preparation now that the HIPAA 5010 forms transition is under way, said Mark Morsch, vice president of technology at Eden Prairie, Minn.-based OptumInsight.

“We’re seeing the level of awareness at the C-suite level that wasn’t there a year ago,” he said. “It has become more of a front-burner issue now.”

Pradep Nair, senior vice president for healthcare at Florham Park, N.J.-based HCL Technologies, says with other initiatives like meaningful use going on, providers haven’t focused on ICD-10 but are now starting the process in earnest.

“Many are looking at the impact and drawing plans,” he said. “Impact analysis is the place to start – finding out what needs to be done.”

Well beyond IT

Another misconception among providers is that ICD-10 preparedness impacts information technology the most and is therefore the sole responsibility of the IT department.

“There needs to be recognition that ICD-10 is not just coding or health information management, but that it spans the enterprise, from clinical to revenue cycle to reporting and analytics and the future of healthcare reform,” Morsch said. “That means everyone has to be aware, including physicians, the care management team and the administrative team as well as HIM and HIT. It has to be a multi-disciplinary approach and the conversations need to address the impact ICD-10 will have on the entire organization.”

To be sure, the ICD-10 implementation means “putting your house in order,” agreed Edifecs CEO Sunny Singh. “Before you can collaborate with your business partners you have to collaborate internally.

Collaboration is most important because ICD-10 truly impacts reimbursement and you need to form solid partnerships with payers.”