August 3, 2015

ICD-10 Offshore Coding: “Caveat Emptor”

By Anonymous MD

EDITOR'S NOTE: The following article constitutes a transcript of comments recently made exclusively to ICD10monitor.com by a former representative of an offshore coding entity who requested to remain anonymous.

With ICD-10 go live on the horizon and the predicted production drop, many of you have found or are scrambling to find a vendor partner to make up the deficit for your current coders come the first of October.

One solution is offshoring. It is the term applied to coding conducted in English speaking countries.  Examples of countries that are currently offering coding are the Philippines, India, the Bahamas, UAE, and the latest entry could be England.

For those of you who have a vendor partner in the U.S., your resource coders are probably not U.S. based coders. Many U.S. outsourcing coding vendors are either building a team offshore or they are partnering with a team offshore to provide coding services for U.S. based clients.

Of course there are benefits to offshoring; the number 1 driver is cost. As chief financial officers  around the country look at their P&Ls to decrease expense one of the drivers is salaries and benefits. Offshoring provides a relief not only on the salaries but on the ever rising expense of benefits. The other benefit is that the offshore pool of coders is a much younger population than the onshore coders. The ages vary from 20 to 30 while the onshore age is more in line with 40 to 50 ranges.

What are other benefits to offshore coding? In the Philippines all the coders are predominantly nurses that are an asset for the specificity and CDI requirements of I-10. The India coders although not nurses for the most part are college graduates with a degree in PT, pharmacy or other disciplines such as bioinformatics, microbiology, or biotechnology. 

Although everyone is highly intelligent and speak the English language, when it comes to chart interpretation of data their ability to self-interpret documentation in the medical record is low and hence one of the many problems with offshoring. Some examples: since India is predominantly a non-alcohol country, any mention of social drinking such as drinks one drink per day is automatically coded as “alcoholism.” Another example is the word eloped; it doesn’t necessarily mean that the patient has left AMA because the translation is not found.  So the nuances to “American” English if oftentimes either not translated correctly or omitted from translation into an essential code. The other problems consist of the coders themselves. Companies overseas are onboarding college graduates and yes they are put in a classroom setting anywhere from eight hours per day for 40 days up to 70 days depending on the type of specialty needed. However, once educated they are released to on the job training at the project level for a few weeks and then they go live. This is extremely problematic because as most of you know seasoned coders in the US even if they are transitioning from another facility will take up to three months to acclimate to a new facility.  Yet, the expectation is that brand new coders coming out of education in any of the countries will be up and ready fully able to output the expected production of a seasoned coder. This is an impossibility but that is how the contracts are set up. There are some companies that are able to meet these specs because unbeknown to you they have “buffer” coders. What are “buffer” coders? Those are coders who utilize the login of another coder in order to maintain the output. Or the coder leaves and the information is not communicated to you and a new confidentiality agreement is not signed, the old login not terminated and a new login not issued. So many issues with this! First and foremost this is a HIPAA violation, especially since you have a record of the first coder signing a confidentiality agreement but not the second coder, and second when you do an audit do you know whom you are actually auditing? Those are questions to ponder.

The other way the offshore company meets those specs is forcing the coders to work mandatory overtime. This would be ok if it was a temporary solution but it is a continuous solution to a very big problem. I don’t know about you but if I had to code 12-hour days six and sometimes seven days a week, my output might be there but the quality will certainly not be.

Most coders in the U.S. tend to stay with a facility a number of years if not a lifetime. However, because of the rise of many outsourcing companies in other countries “poaching” has become a norm. What is “poaching?” That is when a competitor openly approaches a coder either outside the company or at a testing site and lures them with the promise of a better offer. So this sets up a revolving door. The constant egress of staff with experience and the constant need to fill the positions with new coders.  Are you aware, that any of this is happening with your contracted coders?

So now, let’s discuss quality control. Yes, auditing does take place in the offshore world but not auditing as we know it. Auditing is oftentimes another inexperienced coder or someone with 3 to 6 months additional experience than the first coder. The other factor is that when the coders are taught in the classroom setting they are not taught payer guidelines or medical necessity or any other important aspects of coding. Those factors if at all discussed are taught at the account level as part of the out the job training (OJT).  We in the U.S. are at least aware of the different payers and guidelines but the folks in these countries haven’t any knowledge of payers. It is a foreign concept to them. They, for the most part do not see remittance advice. Compliance auditing is non-existent and the offshores should be scared to communicate with the client to let them know if there is a potential problem. The offshore teams have little or no knowledge of the Office of Inspector General (OIG) and how the U.S. government views potential fraud and how they relentlessly pursue potential offenders.

So what should you do to protect your facility or practice from ever having the FBI/OIG come knock at your door?

  • Make sure that HIPAA privacy and security mechanisms are in place. Hold the vendor accountable as part of the contract that any fees associated with HIPAA investigation or coding “fraud and abuse” potential is their liability. Make sure that any business associate agreements, policies and procedures have clear remediation clauses and penalties for breach.
  • Make sure that the Quality assurance is secure and not just a smoke screen: That there are two layers of quality assurance reviews (one offshore and one within the US) with additional experience required for offshore quality assurance teams and as a precautionary measure contract with a US coding company that has seasoned auditors to monitor the offshore coding centers.
  • Also, for those who have managed care contracts check with the payer if there is a requirement that you file paperwork with them noting that your coding is being done offshore. You may be in breach!

Although offshore might look like a viable solution to your staffing and financial needs make sure through reporting and question sessions that everything necessary to protect your facility/practice from that knock on the door is being done correctly.

As they say caveat emptor as it translates to "let the buyer beware." Don’t let the phrase translate to "sold as is" and you and your facility will be exposed to an OIG potential financial burden.

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