November 11, 2013

Clearinghouses: Important Players in the ICD-10 Transition Coming Next October

By Tim McMullen, JD, CAE

Cooperative Exchange, the national association representing organizations in the healthcare information technology and transaction industry, held its membership meeting last month in San Diego during the MGMA National Conference on October 8.

The number one topic of discussion: Transitioning from ICD-9 to ICD-10 on October 1, 2014, and the clearinghouse role. The 17 clearinghouse members agreed that we are the EDI subject matter experts capable of assisting with end-to-end testing—the movement of data that is within the X12 transaction—and that’s where our strengths lie. 

Clearinghouses have the ability to deploy proven testing solutions/products early in the project, whether they require movement of claims data, remit data, or eligibility data between providers and health plans. A clearinghouse can develop testing guidelines and schedules between providers and payers to keep them from getting too close to the deadline as well as getting them into the proper cycle when there are many entities testing at once. 

 

At this meeting, we took time to develop a list of the ways members are helping their provider clients.

Identifying Current Payers and the Relationship Providers Have with Each:

  • Clearinghouses can help providers ID their high-volume payers for claims/remits/eligibility/etc.;
  • Provide information about those payers;
  • What acknowledgements/claim status information is being returned; and
  • Whether payers are receiving provider claims in the 5010 format.

Validate Transaction Compliance:

  • When the provider will be able to send/receive 5010 transactions; and
  • What test cases will they be testing.

Facilitate Payer Testing:

  • Review the process for conducting testing;
  • Conduct payer testing using actual test cases between providers, trading partners, and payers;
  • Validate acknowledgements/claim status transactions;
  • Review any rejections generated from the trading partner or payer;
  • Track if payer is able to return test remittance advice; and
  • Review any denials.

Bridge “gaps”:

  • Review any format or data content that fails to provide “clean” claims;
  • Review any edits or customization that need to be modified from ICD-9 to ICD-10;
  • Recommend any actions needed for either the provider or payer;
  • Encourage multiple iterations of testing; and
  • Serve as a depository of issues.

During the discussion, members felt it was necessary to make a list of what clearinghouses cannot do for the provider community. They:

  • Cannot provide guidance or testing on changes needed for clinical documentation;
  • Cannot update practice management systems or hospital information systems;
  • Cannot perform an impact assessment of the provider’s business;
  • Cannot translate the ICD-9 to ICD-10 or ICD-10 to ICD-9;
  • Cannot evaluate changes that must be made with payer contracts; and
  • Cannot predict reimbursement outcomes.

As with the transition from 4010 to 5010, clearinghouses will be the first call providers make when they have issues with ICD-10.  Therefore, Cooperative Exchange and its members are working hard to ensure their provider clients are ready for ICD-10 implementation through targeted education webinars, testing, and consulting.

Cooperative Exchange was established in 2002 to promote and advance electronic data exchange for the healthcare industry by improving efficiency, advocacy, and education to industry stakeholders and government entities. 

Members include: ACS EDI Gateway; American Medical Association (AMA); AXIOM Systems, Inc.; Availity; CareMedic Systems; Capario; ClaimLogic; Claimsnet; eProvider Solutions; Gateway EDI; GE Healthcare; GHN‐Online; HDM Corp.; Healthcare Billing and Management Association (HBMA); Health-e-Web; Jopari Solutions; Medical Electronic Attachment (MEA); NextGen Healthcare; OfficeAlly; OptumInsight; RealMed, an Availity Company; Secure EDI; Siemens HDX; The SSI Group, Inc., Streamline Health, WEX, Inc. and ZirMed.  

In 2010, Cooperative Exchange members connected with over 60 percent of all submitting providers and more than 5,200 payer connections and processed more than 1.2 billion claims transactions with a value of over one trillion dollars.

About the Author

Tim McMullen is executive director of the Cooperative Exchange

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