Updated on: September 23, 2014

Testing with Payers: Feedback and Good News from Two Blues and a Commercial Payer

By Betty Gomez
Original story posted on: September 22, 2014

In my last article for ICD10monitor, I shared feedback that ZirMed received from our clients — individual providers as well as clinics, physician groups, and hospitals. As promised, this time around I’m going to share feedback from a few of the payers we’ve tested with; specifically, it was end-to-end testing with a Blue and a commercial payer, and syntax testing with another Blue.

The feedback is detailed, so I won’t preface it with too much additional content. But I will point out one common theme: payers are just as concerned with testing as providers are.

Or, to be more precise, payers are just as concerned as providers should be.

What are you seeing overall as far as testing and results?

“Prior to the April 1 delay, we saw a marked acceleration of interest from physicians, providers, and external third parties in our three-phased ICD-10 end-to-end testing process. The experience was very much in line with what we saw during the NPI and 5010 transitions — the closer you came to the compliance date, the more interest you were getting from these entities.

Unfortunately, once the delay was announced, we saw an immediate drop-off. The entities that were already in the pipeline kept their engagement and momentum moving forward, but we essentially lost new entrants. We’re currently seeing a stabilization of interest, but also a certain degree of calmness given that we’re almost 13 months out. And that’s a dangerous position to be in.

Given the challenges and given the collaboration and coordination that is needed for any end-to-end testing process to work correctly, the time to test is now. Given the gift of the delay, we must take advantage of this window — or pay the price post-implementation!”

– Blue No. 1, Southeastern U.S.

“We’ve been testing with large facilities, principally focusing on identifying DRG payment variance due to shifting. Of the 43 facilities we’re currently testing with, 22 are in our second stage. Most facilities recognize the need for a robust clinical documentation initiative to document the additional content needed to support more specific coding — so most facilities have continued with their testing initiatives despite the delay.  

In the second stage, providers typically submit 50-300 claims specifically selected because they map to high-risk DRG conditions (i.e. most likely to produce payment variation). Providers recode from medical records in ICD-10 and submit for pricing and evaluation. 

In stage three, providers submit a similar volume and case mix of claims electronically for adjudication and remit return. To date we find that payment variations are much smaller than simulations predicted. Facilities are quickly becoming proficient in accurate ICD-10 coding and documentation is being adjusted to support ICD-10 specificity.”

– Commercial Payer

What are the challenges? The successes?

“(One challenge is) building and maintaining interest in ICD-10 testing among providers. The truth is that there are competing priorities. We recognize that and we look for ways to make the case for why testing needs to be at the top of the list. The other side of that is the challenge of making it easy for providers to test with us — and that’s one place we feel we’ve been successful.”

– Blue No. 2, Midwest U.S.

“The greatest challenge begins with outreach and engagement of something that is very new! For previous regulatory mandates, we did not have effective external end-to-end testing capabilities. This left the physician, provider, or external third party at the (mercy of the) capability of their electronic trading partners to help ensure compliance. ICD-10 is a lot different — there are no technological silver bullets here.

ICD-10 requires technical and business process changes from the clinical setting to the administrative setting of healthcare and everywhere in between. Your electronic trading partners may well be capable of transporting ICD-10 codes, but you have to determine if you are sending the ‘right’ ICD-10 code that more accurately represents the clinical condition of the patient — that is the clinical challenge. And are we having success? Yes, across both the clinical and administrative settings.”

– Blue No. 1, Southeastern U.S.

Are providers getting the most out of the testing?  

“In my opinion, not as much as they could. ICD-10 testing should focus more on the code content rather than (end-to-end) testing. Often the focus on E2E testing is based on ‘the way business has always been done’ and the concept of focusing on code content testing is lost in the mix.”

– Blue No. 2, Midwest U.S.

“We would certainly hope so. From our perspective, definitely! For the first time we’re able to take an electronic transaction that originates from the physician or provider’s clinical setting and pass it to our ICD-10 testing environment through to full adjudication and reconciliation. We do this with all standard security and protection protocols in place so as to protect the PHI that is being shared. We do not have to make up data and coordinate it across the chain of trust — this is real member and patient data, just with ICD-10 codes.”

– Blue No. 1, Southeastern U.S.

From your perspective, what do providers need to do in order to conduct and/or get the most out of the end-to-end testing?

“Engage coders in dual coding internally ASAP. Assign your best coders, administrators, and revenue cycle managers to the evaluation.”

– Commercial Payor 

“The most important message to send to physicians and providers is to get engaged now. Talk to your health plans and see how you can start testing with them. If a health plan is not ready, then simply call another — but don’t hesitate. The sooner you get engaged, the better off you’ll be – ICD-10 is not a trivial activity that can ‘wait until later.’ If you’re (a provider in my state), just call me and we’ll get you started!”   

– Blue No. 1, Southeastern U.S.

“I believe the key to ICD -10 success in part lies with the small professional providers. Historically, this group has been underserved in the testing arena. This is because they often don’t have the resources to commit to traditional testing requirements. We need to make content-based testing capabilities available to as many small professional providers as possible with as little administrative/staff burden as possible.”

– Blue No. 2, Midwest U.S.

You might notice a theme: test now, because this isn’t a pro-forma exercise. Providers who are testing with payers are discovering specific, actionable changes or adjustments they need to make to limit the operational or financial impact of ICD-10.

The other common theme — at least the one that stuck out to me — is the need for collaboration. Payors recognize that providers’ systems and workflows may not be fully ready for ICD-10. But through coordination and communication between providers, vendors, and payers, testing doesn’t have to be delayed just due to the go-live date being pushed back. And that’s good news.

About the Author

Betty Gomez directs ZirMed’s regulatory strategy.

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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.