David Alves:
The healthcare industry is undergoing unprecedented change at this time. Over the past few years, the industry has weathered the "Perfect Storm" of regulations and new initiatives, as they move forward into today's pervasive and omnipresent Information Technology (IT) world. One of the most daunting of these initiatives, and the one that is most likely to have an impact on the bottom-line, is the move from the International Classification of Diseases, Revision 9 (ICD-9) to the International Classification of Diseases, Revision (ICD-10). On one hand, ICD-10 allows for much more precision in the clinical documentation utilized for processing and paying claims, allowing us as a society to classify much more information about current health care services, and allowing us to catalog new diseases and new advances relative to new and old diseases as society moves forward. On the other hand, it will involve enormous costs in training staff, changing healthcare processes and procedures, and the remediation of revenue cycle hardware and software systems that process the claims relative to healthcare services.
As consultants in the field of software quality and risk management, it is the aforementioned software changes to these systems that has us at GQP most concerned. In today's world, the volume of claims processed per day, through any one insurance company, which is also the life's blood of most service providers, is far too much to process any significant volume by hand. Therefore, these revenue cycle systems must work, or services and related payments will be greatly affected. No training or process improvement or adaptation activities will remedy this problem, just time, and the proper methodology of experienced experts. Healthcare.gov is the perfect example of this. However, most private sector payers do not have the same resources or pull as the U.S. government to bring to bear on the problem in order to get back to business so quickly (and I use the term “quickly” lightly when referring to Healthcare.gov). I am sure the preferred approach is to do it right the first time.
The largest consumer of insurance claims is Medicaid/Medicare. If your revenue cycle systems are not ICD-10 compliant, you will not be doing business with the U.S. Federal Government, the largest Healthcare payer on the planet. The most recent deadline to be ready, up until 4 or 5 months ago or so, was October 1, 2014. Most Providers/Payers were not going to be ready, and made their voices heard. The Feds listened, and the date was moved out 1 year to October 1, 2015. No one foresees another extension being granted at this time.
So, here we are, with just over a year remaining to "do it right the first time", and the question is, is the industry making the most of it? Are they truly managing their risk?
Over 1 year ago, I wrote the initial draft of a whitepaper on this subject, which addressed this very issue. It was never published. Here we are 1 year later, and the question is just as relevant. What's even better though, is the industry, as a whole, has even more time to address the challenges this problem presents. Click this link here, and you can read GQP's thoughts on the issue, our recommendations, and the solutions we believe can help you quantifiably say, "YES, our organization IS truly managing our risk"!
posted by: David Alves
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