September 28, 2015

What Do We Really Know About Oct. 1, 2015?

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Although many got a laugh (or were completely confused) by former Secretary of Defense Donald Rumsfeld’s infamous convoluted answer to a question, it seems it was prophetic of where we are on the road to ICD-10.

“There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know,” Rumsfeld said. “But there are also unknown unknowns – the ones we don't know we don't know. And … it is the latter category that tend to be the difficult ones.”

 

We know exactly how Centers for Medicare & Medicaid Services (CMS) testing with the traditional Medicare fee-for-service plans went. We know how successful end-to-end testing with various Medicaid and commercial plans has been to date. We know which plans were especially problematic in testing. We know which systems, software, and vendors are thoroughly tested and working optimally. We know which ones were not ready on a timely schedule, therefore handicapping testing and preparation. We know which practices have mastered excellent documentation and which ones are still struggling. We know the CMS policies and some other payer coverage polices for ICD-10. We have detailed findings for every payor who conducted full end-to-end testing to help us make informed decisions. We know that some companies, practices, physicians, and/or entities have not prepared and are still praying for a last-minute reprieve. In a nutshell, we know a lot. I think Mr. Rumsfeld would characterize these as the known knowns.

We also know that some payers will rely upon proprietary internal mapping programs to convert ICD-10 to ICD-9 for adjudication purposes. Unfortunately, we have no idea what the result will be. How do you appeal a denial when you don’t know what mapping created or contributed to the decision? Will there be recoupment later or allegations of false claims if erroneous mapping results in improper payments? How much additional work and cost will result from these programs? It should be glaringly obvious that these types of solutions will not result in the data accuracy necessary for future quality, utilization, or other initiatives. The great unknown is why this was permitted when it has been a point of concern for many years, with repeated testimony decrying the process. There was plenty of time to do it right. 

We also don’t know how all the programs and systems that were not updated in a timely fashion will function in a real claims environment. We know that many surveys reported that vendors were promising the release of the ICD-10 updates in July. Unfortunately, that was too late to test in some cases. Another example is a major payer that did not initiate any testing until the end of July, with results are not yet known. Fewer than 30 business days is not enough time to make any meaningful or complex corrections. It is certainly too late to surprise providers with bad news. We know we have a plethora of programs, systems, and software that will go live without the benefit of full end-to-end testing. Logic dictates that not all will work as planned, in spite of assurances to the contrary. Hopefully, prudent people planned for the inevitable problems that are sure to arise. I believe these are our known unknowns.

In conversations with many physicians, practices, and billing companies who have dedicated time, resources, training, and money to prepare, one consistent theme surfaces. They are scared to death about what will happen. They are as ready as possible, but don’t feel any sense of comfort. With few exceptions, we all deal with hundreds of payors and thousands of plans. We’ve been able to successfully end-to-end test with a tiny handful, if any. We have little or no information about their processes, policies, and readiness. Everyone is hoping for the best but planning for the worst. We truly do have many unknown unknowns. I think perhaps that is the saddest part of the story. We have far more unknowns than knowns at the eleventh hour. What other industry or business functions like that and survives? 

I hope we are all simply paranoid and overreacting, and that we will be looking in our rearview mirror at another Y2K experience and laughing in November. 

In preparation, however, I’ve ordered a T-shirt with a saying attributed to a bomb squad: “If you see me running, try to keep up.”

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.

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