Updated on: March 16, 2016

The Little Guys Did it Perfectly

Original story posted on: April 28, 2014

The shocking announcement that ICD-10 implementation has been delayed again received a variety of responses, ranging from elation to “I told you so” to complete frustration. Although we don’t know if and when another implementation date will be confirmed, we do know that many providers have made major progress toward readiness. The great unknown to date is this: will testing be representative of live claim adjudication? Will claim disruptions be minimal or catastrophic? Will the payor triage system for testing partners be too limited, only involving the largest partners? Based on historical experience, many have reason to be very concerned about the capabilities and readiness of the Medicaid plans. But Idaho Medicaid recently hit an out-of-the-park home run demonstrating just how well claims adjudication can work at the physician level. And if they can do it, so can everyone else.


Late last year I had an in-depth discussion with a representative from Idaho Medicaid regarding our company’s willingness to work with them when they were ready to test. As a result, Medicaid and their claims processing contractor’s ICD-10 implementation team reached out to our third-party medical billing company to serve as their beta testing partner for physician claims early in 2014. It was immediately apparent that they had invested heavily in the work required for the ICD-10 transition. The planned testing included full end-to-end adjudication (837 and 835) with the correct claim adjustment reason codes (CARC) and remittance advice remark codes (RARC) based on the correct coverage policies. To ensure a representative sampling, our billing company was to submit claims using both a proprietary system and a purchased practice management vendor system billing software. Accounting for claims processed directly and through a clearinghouse was also addressed. Lastly, multiple specialties and physicians were included in the testing. A coder certified in both ICD-9 and ICD-10 was to assign the diagnosis codes used for adjudication comparisons so we could mirror our normal coding processes.

Idaho Medicaid shared its work plan with us, and testing details and dates were confirmed through phone meetings. Preparing the test batches was a simple programming process for our company and our vendor. Test claims were submitted in a separate batch at specified times so the Medicaid workgroup literally could watch how the claims were processed through their system. Immediate feedback on any issues was provided via email and phone calls. Some very minor technical data entry problems on our end were quickly corrected, and all claims and batches were processed correctly. We then reviewed the adjudication to identify any ICD-10 claims that appeared unexpectedly or had a different result than current claims. Again, no problems were identified. The entire testing process was so smooth that it was completed more quickly than anticipated in the work plan.

So, what were our teachable moments and takeaways from this experience? First, there are payors that will test with smaller practices, companies, and physicians – not just the large hospitals or major submitters. Second, take advantage of beta testing opportunities. In fact, go look for them! Talk to your vendors, clearinghouses, and payors. Even though we are now in a holding pattern, we can use the additional time to perform and perfect the work required for the smoothest possible transition. Last and most importantly, claims and payment disruptions can be minimized and possibly avoided if we all work together as one team.

I plan to use this experience to pressure our other payors to perform similar testing. If the little guy can do it, so can they. Kudos to Idaho Medicaid.



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.