Updated on: September 23, 2013

What’s the Worst that Could Happen?

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Original story posted on: March 15, 2013

We deal with decisions all the time.

As such, everyone has some means of weighting the pros and cons of any given choice. Many years ago, I read something that I have used ever since as a tool of my own in making significant decisions. You are supposed to ask yourself the question, “what is the worst that could happen?” for each of your options.

It’s a way of forcing yourself to acknowledge risk and its consequences. If you can live with the worst-case scenario, then you have a viable option. If you can’t, you better look to another choice. This approach forces us to take off the rose-colored glasses, to see the glass as half full, and this prevents us from assuming that everything will work out.

I was reminded of this because of recent conversations with two people currently managing large projects on the payer side of ICD-10. In the first conversation, my associate pointed out that more than 10 percent of providers are not submitting claims using 5010. They rely on their clearinghouses to convert transactions to 5010 for them. His point is that even something as relatively simple as 5010 (when compared to ICD-10) is not a slam dunk. He doubted that the clearinghouses would offer a similar service to upcode from ICD-9 to ICD-10 because of liability. This brings us to the worst thing that could happen. He asked what would happen if a significant number of providers are not ready for ICD-10 and the volume of paper claims increases nationwide. In his view, the cost implications are significant, and something the organizations in question might not be prepared to handle.

In the second conversation, the payer talked about the analysis that his organization had done on the impact of provider readiness. What would happen if providers could not code properly or submit claims electronically? Claim rejections would increase. This payer was very worried about the cost of reworking claims and the potential to have to perform manual adjudication. They looked at what would happen to their call centers, with big spikes in volume driving up cost as panicked providers called to find out why they weren’t getting paid. Would there be a spike in paper claims, too? And if so, how would they address that additional cost?

A frequent observation about our healthcare system is that there is not a lot of spare cash floating around. Providers have limited reserves, which underscores the real problems of meeting payrolls and paying bills if the worst that could happen does happen.

Both of these conversations are good examples of asking the question: what is the worst that could happen? Both organizations quantified the impact, which in both cases could be significant. They both concluded that these costs were avoidable (or could be minimized) if the providers are better prepared.

It is interesting that both advocate making an investment in assisting providers (an ounce of prevention) rather than setting up costly contingency operations (a pound of cure).

About the Author

Hugh Kelly is the Vice President of Marketing and Sales for Avior Computing. Mr. Kelly has more than 20 years in the software and technology business at organizations ranging from start-ups to publicly traded companies. Mr. Kelly has been involved in all aspects of marketing and sales, with considerable focus on channel development.  During his executive tenure, his organizations have raised over $200M in external capital.  He is a venture partner at Ascent Ventures.

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