Updated on: November 28, 2016

Good News, Bad News

By
Original story posted on: January 18, 2016

To date, most accounts of ICD-10 implementation are good ones. Claims are processing, providers are being paid, denials are minimal; it was all much ado about nothing. Or was it? For some unlucky practices and organizations, things did not (and are not) going quite so well. 

Based on anecdotal reporting to date, it appears that some specialties and some system and software users fared much better than others. It also appears that larger billing companies are reporting fewer issues than smaller ones.

A major code assist product had total system failure on Oct. 1, and it is still not up and running successfully. All the clients that relied on a previously excellent product were (and are) struggling to overcome such an unanticipated catastrophic failure. Some proprietary coding systems did not perform any better. It boggles one’s mind that X-rays of the ankle, hip, knee, etc. could somehow be coded as mammograms! One company reported that it hired an additional 25 coders to manage the work. Others could not find experienced coders and had to resort to unplanned outsourcing. Outsourcing has gone smoothly for some, but it has been a very bumpy road for others.

Many companies that perform coding reported that they were inundated with pleas for help at the last minute. Of course, they could not suddenly produce an adequate number of proficient coders in myriad specialties and subspecialties. Issues for some are still not resolved, and some are engaged in on-the-job training: a very suboptimal position to be in at this point in time. This issue is compounded by an almost universal reporting that coder production has not yet reached previous levels – at least for physicians.

An obvious outcome of situations like the ones described above was a sudden cessation of claims submission and/or large backlogs of work. Companies are reporting that they could not submit claims on behalf of their providers for extended periods of time (late November or December was reported by several companies). The unplanned and unanticipated challenge was whether to release claims that had not had the normal levels of scrutiny and due diligence in order to get money flowing again. Most are reporting that the need for cash flow outweighed the risk of some incorrect claims.

Not unexpectedly, the accuracy of many claims must be questioned. Unintentional errors were and are being made, perhaps in higher numbers than expected. Whether or not they result in incorrect payment of claims or excessive denial of claims, it is still a problem. Around the industry, many are reporting a sudden surge in employment opportunities for denial management specialists, and coding positions continue to be available in large numbers.

An increase in patient complaints has also been reported. I believe that planning for eventual audits and findings of incorrectly paid claims needs to be high on everyone’s priority list. In addition, customer service staffs need to be trained in appropriate responses to complaints from patients and insurance plans (to which the patient often also complains). The very last thing anyone wants or needs is a fraud unit investigation in response to patients reporting that their bills are erroneous.

We have also had reports that some small companies simply closed their doors and disappeared, leaving clients without services. 

Based on the above information, HBMA will be deploying a survey to assess the current baseline in our industry. Are the above experiences isolated? Are they more widely spread that has been reported? What will happen if and when increasing requirements for specificity are implemented and payor edits are turned on?

Although it does not help those who are struggling, we hope these are isolated issues and not the tip of an iceberg.

 

Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.
Holly Louie, RN, BSN, CHBME

Holly Louie is the compliance officer for Practice Management Inc., a multi-specialty billing company in Boise, Idaho. Holly was the 2016 president of the Healthcare Business and Management Association (HBMA) and previously chaired the ICD-10 Committee. Holly is also a national healthcare consultant and testifying expert on matters related to physician coding, billing, and regulatory compliance. She has previously held compliance officer positions in local and international billing companies. Holly is a member of the ICD10monitor editor board and a popular guest on Talk Ten Tuesdays.

Related Stories

  • Things Your Mother Never Told You About HCC: Version 23
    The 2019 CMS risk adjustment model is version 23. The Centers for Medicare & Medicaid Services (CMS) released, in April, the latest update to the CMS-hierarchical condition category (HCC) Risk Adjustment Model (V23).  It applies to payment year 2019.  As…
  • Random Thoughts about ICD-11
    New classification system noted for granularity. Several of my colleagues recently attended an ICD-11 presentation by Kathy Giannangelo[i] at the American Health Information Management Association (AHIMA) Convention & Exhibit. Kathy has been in the trenches with ICD-11’s development for some…
  • ICD-10 Coding: HPV Cancers
    Local radio station personality goes public with his cancer fight. In August 2018, Marty Griffin, KDKA radio personality, announced to his listening audience that he had cancer. His cancer is related to human papilloma virus (HPV), which infects 80 million…