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OBSTACLES STILL TO COME WITH ICD-10 ACTIVATION

By: Nicola Heredia, CHS Marketing Coordinator

After several years of planning, training and preparation, ICD-10 was officially activated on Oct. 1. Although the industry anticipated obstacles to arise, many providers, coders and physicians had taken steps to ease the transition from ICD-9 to ICD-10 codes.

“It was somewhat similar to Y2K, we worked like demons and everything proceeded the way it should have,” said Sid Herbert, director of the ICD-10 implementation team at Humana, in a Diagnostic Imaging article. “That’s not to say it will continue that way, but I think we have enough data that says we won’t have major catastrophic issues.”

Overall, industry leaders report a relatively smooth transition since ICD-10 was implemented.

In the span of one day, the medical industry was faced with reporting medical diagnosis with 14,000 to 68,000 codes. The level of specificity of the ICD-10 system will result in claim denials, lower productivity and slower processing times, which is an expected aspect of the transition period.

“ICD-10 requires a certain amount of data precision that doctors have not been used to,” reported Peter Strack, senior advisor for the Altarum Institute, in a Next Avenue article. “With five or six times the number of codes than before, there are a lot more decisions to go through for every claim.”

Deborah Grider, an AHIMA approved ICD-10 trainer, wrote a blog for ICD-10 Monitor, identifying specific struggles that have come up since ICD-10 was implemented.

Here are a couple of the major obstacles that Grider believes the industry will face in the short-term.

  • Coding Struggles: Hospital coders that are not comfortable with ICD-10 are struggling with choosing codes based on the documentation they have been provided.
  • Physician Error: Many physicians have still been using ICD-9 codes for referrals even after Oct. 1, delaying patient’s from seeking care since the referrals have to be sent back and corrected.
  • Delay in Payment: Once of the biggest concerns is that due to coding errors, claims will be denied resulting in a lack of payment to physicians and higher bills sent to patients.

Although the initial implementation of the new coding system appears to have gone smoothly, experts anticipate the biggest obstacles to arise when the ICD-10 claims are first being processed. Claim denials have been a big concern since ICD-10 deadline was first set.

The Centers of Medicare and Medicaid Services, CMS, initially predicts that errors reported in claims will be more than two times higher with ICD-10. The organization is anticipating denial rates to rise 100 to 200 percent following the initial implementation of the coding system.

Navicure/Porter Research conducted a survey to determine what issues organizations are anticipating will arise as a result of ICD-10. The study’s results reported that one in three healthcare organizations have failed to make changes to their income cycle in an effort to prepare for revenue interruptions that will inevitably occur in the near future.
 
“While some organizations are being proactive in other areas to improve revenue and cash flow, including improving patient collections (34 percent) and patient price estimation (17 percent),” claimed Navicure/Porter research. “35 percent have not adjusted their revenue cycle in preparation for ICD-10.”

Everyone from patients to physicians will feel the effects from ICD-10 claims being processed. Doctors' offices may see a delay in cash flow, while patients may see higher bills due to coverage denial from insurance providers. Experts encourage all within the industry to push back on the denials to ensure that payments and claims are processed correctly.

“We’re only at the beginning of the journey,” said Herbert. “I’m hopeful the issues will be small, but be assured that it’s in the payers’ best interest to actually pay a claim quickly, accurately and effectively. Anything beyond that causes rework and dissatisfies the provider, so there is no real positive result.”

GROWING SUPPORT FOR VALUE-BASED HEALTH CARE WITHIN INDUSTRY

By: Nicola Heredia, CHS Marketing Coordinator

The American health care system has undergone tremendous reform since the activation of the Affordable Care Act. Many aspects of the reform law have forced those within the industry to shift their business models in order to be successful in this new era of health care.

Traditionally, the U.S. health system has operated on a fee-for-service model, which would allow providers to be compensated based on the number of services provided to patients. Supported by the federal government, value-based care is the latest model to gain traction as a way for those in the industry to cater to their patients with a different approach.

“Whether you are a patient, provider, a business, a health plan or a taxpayer, it is in our common interest to build a healthcare system that delivers better care, spend health care dollars more wisely and results in healthier people,” said Sylvia Burwell, U.S. Health and Human Services secretary, HHS, in a Health Leaders Media article. “We believe these goals care drive transformative change, help us manage and track progress and create accountability for measurable improvement.”

As out-of-pocket costs and insurance rates continue to rise, Americans are becoming increasingly more involved in their health care. Individuals have high expectations when it comes to the level of care that physicians offer. More and more patients are shopping around prior to selecting their doctor. to ensure they get the best value for their money. 

The trend of providing a more value-orientated care is directly tied to consumers wanting to better understand what they are paying for. Their increase in involvement in their health care has forced both providers and payers to make adjustments in order to retain their business.

“Making care available to consumers during off hours, and expanding locations will distinguish one health system from the next,” reported the PwC’s Health Research Institute report in a Becker’s Hospital Review article. “Identifying and closely working with consumers, especially patients with multiple conditions, improves outcomes and lowers costs.”

Health care costs in 2013 topped $2.9 trillion and experts believe that costs will continue to increase annually by 5.7 percent. When it comes to spending, the primary reason for high costs is due to the system paying for quantity and not quality of care.

Using a value-based health care model could shift how money is spent; potentially leading to a healthier population that has more ownership in their medical health.  By 2016, the HHS anticipates that 30 percent of Medicare spending will be toward value-based care, which will increase to 50 percent by 2018.

In order to shift towards this type of care, everyone from physicians to payers must work together.

One of the biggest medical costs comes from treating patients that suffer from chronic illnesses. In an effort to manage those diseases, patients have to be diligent about following up with physicians and committing to their prescribed regimen.

According to a Philly Tribune article, one in two patients fail to adhere to their medication as prescribed by their doctor. This can lead to costly trips to the emergency room and hospitalization. The lack of follow-through on prescriptions cost the system nearly $300 billion annually.

“Not to sound harsh, but in the past it wasn’t part of the business model for the provider to care about whether that kid fulfilled that script because when they showed up in the ER the provider was going to get paid for it,” said MedeAnalytics CEO Andy Herd in a Health Care Finance News article. “But today in a value-based reimbursement, they’re going to get paid a single amount of money to manage that child’s asthma care. It’s now in the provider’s best interest to understand who filled that script.”

Following up with patients to ensure them are managing their illnesses as directed is important to not only gain control of their symptoms, but eliminate costly hospital trips and medical complications from arising. Encouraging physicans to play a bigger role in managing a disease instead of simply treating it during a patient's visit is one of the biggest shifts in mindset that must occur in order for value-based care to be implemented.

As with other changes that have occurred in the industry, the trend toward focusing on quality of care is met with skepticism and critics. However, this shift is necessary in order to control chronic illnesses and rising health care costs, while also remaining competitive and retaining patients' business in the long run.

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