Overall, payers, providers, and states that participated in last week’s WEDI Property and Casualty Workgroup call reported little to no impact on their day-to-day business operations. Jopari Solutions, a national property and casualty clearinghouse, reported the following worker’s compensation findings:
Jopari Solutions ICD-10 Post-Implementation Early Findings | |
October 1 – November 4, 2015 | Worker’s Compensation Results * |
Total percentage of ICD-10 bills rejected/Total bills received | Less than 1% |
Volume percentage of ICD-10-to-ICD-9 clean claims received | 46% |
Trend in clean claim errors post-ICD-10 | Less than 1% |
Percentage of ICD-10 835 denials | Less than 1% |
Percentage increase in customer support calls | No increase reported |
*Comment: Results reflect reported industry trend across all lines of healthcare business. Too early to determine payment impact. | |
The Top ICD-10 Reported Issues
Not surprisingly, the top reported ICD-10 issues for worker’s compensation mirrored the same issues that are being reported across all lines of the healthcare industry. Below are the top reported issues:
- Top 5 Reported Provider Coding Errors
1. ICD-9 claims with ICD-10 qualifiers (top error)
2. Incorrect I-9-to-I-10 crosswalks due to PMS vendor applications
3. ICD-9 and ICD-10 services on the same bill
4. Invalid ICD-10 qualifiers
5. Invalid diagnosis pointers - Reported Vendor Issues
Vendor date edit errors were creating rejections for runoff ICD claims following ICD-10 implementation
Vendor coding errors created more rejections (all reported issues were resolved within second week).
Few vendors reported system issues; however the ones that did emerge were quickly addressed and not necessarily related to ICD-10 coding. - Reported Payer Comments
To date payers have been reporting ICD-10 claims submission as a non-event, again attributed to solid ICD-10 testing with trading partners. But it is still too early to project post-adjudication impacts.
We would encourage providers to continue monitoring their post-ICD-10 implementation outcomes and track their reimbursement levels to be able to quickly identify and respond to any negative spikes in activity. For those who may not have such baseline metrics in place, we offer the following advice based on the WEDI ICD-10 Metrics Whitepaper, available online at www.wedi.org:
ICD-10 Recommended Provider Benchmark Metrics to Measure Outcomes
- Percentage of front-end rejection error rates
- Percentage of 277 CA front-end rejections by status code/measured over unit of time (usually two-week intervals)
- Revenue payment cycle variance metrics:
- Average time (days) from claims submission to payment
- Denial rate variance metrics (payer/provider benchmarks)
- Dollar amount submitted on claim/amount denied
- Percentage of ASCX12 835 payment denials by type of denial code (CARC/RARC), plus source of initiation (provider, vendor, etc.)
Standard operating metrics: the payers’ standard operating metrics will become increasingly important with the implementation of ICD-10 to monitor the automation, efficiency, and deviation from prior claim payment cycle times. Some of these operational metrics will include:
- Customer service call volumes
Payers can expect an increase in the numbers of calls from providers as they question diagnosis/procedure code billing procedures, check on the status of pended claims, and question the reason for denied claims for billing errors due to policy changes related to ICD-10. This increase in volume may require additional resources to handle, at least during the initial transition period.
- Calls by type
Monitor the types of calls to proactively identify the root causes of underlying issues. A payer may want to monitor call volumes by:- Source of initiation (provider, vendor, etc.),
- Primary purpose of call (authorization, payment discrepancy, payment cycle, medical necessity, etc.)
This information will provide the payer data to support and identify potential impacts of ICD-10 and promote timely issue remediation through systemic and operational efforts.
- Speed to answer
This is an important aspect of customer service, and you will want to ensure that due to increases in call volume, callers do not need to remain on hold for extended periods of time. It may be valuable to include some new pre-recorded messages that answer the most common questions, or refer inquirers to a FAQ site that is robust in providing answers.
- Claims operations
The payers’ claim adjudication performance and operating metrics will become increasingly important with the implementation of ICD-10 to monitor the claim payment automation, efficiency, and any deviation from prior adjudication baselines. Some of these metrics will include:
- Claims auto adjudication rate – Percentage of total claims for a defined period of time that are adjudicated without manual intervention.
- Claims accuracy or rework – Percentage of claims not adjudicating correctly and resulting in rework due to an ICD-10 impact.
- Claim adjudication cycle time – Average days to adjudicate the claim. This metric could be presented by claim or provider type.
- Suspended or pended claim rates – The count and/or percentage of suspended claims by provider type and claim type.
In summary, to date ICD-10 has been something of a non-event for providers, clearinghouses, and payers. We attribute the ICD-10 front-end processing success to solid stakeholder testing protocols, early testing, and ongoing industry educational outreach efforts, which included contributions from ICD10monitor articles and Talk Ten Tuesdays broadcasts.
About the Authors
Tina Greene is a senior regulatory affairs consultant at Mitchell International. She has 29 years of industry experience and serves in numerous leadership roles in national standard-making organizations.
Sherry Wilson is executive vice president and chief compliance officer for Jopari Solutions. She has more than 30 years of industry experience and serves in varies leadership roles with the national standard organization.
Contact the Authors
Comment on this Article
EDITOR’S NOTE: Greene, a nationally recognized industry expert on workers’ compensation, will appear on Talk Ten Tuesdays, Nov. 17, 2015, at 10 a.m. ET.