Where is the Healthcare Consumer in ICD-10 Compliance?

Original story posted on: January 20, 2014

We are in the middle of the rollout of health insurance exchanges of the Patient Protection and Affordable Care Act (PPACA), and there are a few significant lessons the healthcare industry, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) should keep in mind as industry compliance with ICD-10 is sought.

The industry continues to conduct surveys to monitor the ICD-10 readiness of providers, vendors, and payers, however, there are very few activities involving a major player in this regulatory event: the consumer. We know that we are beginning to see increased collaborative activity among providers and payers seeking to align and test for ICD-10 remediation and transition. But where is the consumer in this transition and testing? What will the impact to the consumer be? Do we wait until October 2014 to test the impact on the consumer, much like we have witnessed with the PPACA, or as an industry, do we begin the dialogue, creating a platform through which we can focus attention to the most important player in the business of healthcare, the patient?

As we know, the creation of an I-code for a healthcare event starts at the point a consumer has a reason to pursue health services. There is always a reason for each purchase, and in the business of healthcare, it gets identified and tracked by aligning the purchasing need with a code. Everywhere we can see the healthcare industry becoming more of a digital business, and thus we expect the consumer to use e-tools for pre-authenticating of services, claim tracking, service support, and service referrals (providers).

But where is the intersection between the changes in the ICD-10 codes and the consumers? I would argue that the healthcare consumer is least aware of the changes that will take place in October 2014, among all segments of the healthcare industry. I would also suggest that both payers and providers have not included the consumer in their testing strategies that seek to determine what will change on the EOB, and what it will mean if previously reimbursed services get denied. How many focus groups that include healthcare consumers have been set up in order to assess risks regarding this industry-wide change?

We as an industry need to look at what front-end education will need to take place for consumers to prepare for this change. Are we looking at what information may need to be captured during the pre-authentication process, or possible changes in what procedures may need pre-auth, post-ICD-10?

We know there have been significant efforts in the review and revisions of medical policy, which have consumer implications. Has the consumer been included, though, or are we approaching this exclusively as a coding and internal process change? Have we considered the impact of change on consumer assumptions, or confusion associated with the change? I again would argue that, as an industry, we have not sufficiently considered the consumer, the impact on consumer ratings, consumer loyalty, healthcare-related social media, or other important factors.

Now, let’s proceed down  the process path and look at the consumer access points in the fields of issue resolution, help desks, revenue cycle management , clear communication of what consumers’ out-of-pocket expenses will be, customer service portals or contact centers, customer service phone support services, and claim inquiry hotlines. I have worked with several health plans to redesign customer service strategies, and one of the major missing components in many existing strategies and business models has been the alignment between regulatory change (especially ICD-10) and messaging and issue resolution processes for customer service representatives – from what it means, to how it will impact the consumers, to issue resolution. ICD codes are used to determine eligibility qualifications, and providers can submit requests to inquire about member eligibility, which may be based on services and medical needs aligned with ICD codes. Member management departments receive and handle appeals received from applicants and members, including logging, tracking, reviewing, researching, and conducting hearings and rulings, all in an effort to determine what will this mean for the members. 

Surprisingly, as an industry we have had little dialogue or apparent consideration of the potential for an increased volume of calls from providers and members, which has the potential to impact customer service departments for a minimum of six months.

Have we load-tested the portals, voice-automated claims inquiry systems, etc. for potentially extremely high volumes? While these high volumes will not emerge simultaneously with the compliance date, as with the health insurance exchange enrollment , the frequency can be expected to increase gradually, and we need to plan for increased demand for service to foster customer satisfaction and retention.

There are potential areas of concern and consideration that we as an industry need to address prior to October 2014.

  • Has the industry partnered with groups such as AARP and chambers of commerce to coordinate a consumer communication and awareness campaign? Are we using every form of communication available?
  • Regarding EOBs – Will they look different? Will there be a support process for potential increases in denials? How are we communicating these changes to the consumer?
  • Will there be a potential uptick in point-of-care patient financial responsibility, i.e. additional co-pays for services that may not require a copay or full financial responsibility if services are incorrectly deemed ineligible?
  • Will providers mitigate patient access to care risk due to provider financial risk, denials, and delayed payments due to changes in first-pass rate criteria?

End-to-end testing strategies should have significant consideration given to the consumer, as much of this kicks in at the time the consumer has received care and a bill/claim is starting its way through the back-end process. We have spent time as an industry reviewing the need to improve clinical documentation as a major component of anticipated ICD-10 impact, which is an amalgam of data between the consumer and the provider. How great is the possibility that a provider or consumer could incorrectly define coverage criteria or incorrectly establish limitations or authorization requirements for approved codes? How can this be communicated, and most importantly, what is the adequate issue resolution to the event and who will resolve the issues inherent to the problem? 

We need to make sure that, through the testing process, we test eligibility based on new codes for medical policy changes so that the consumer does not meet incorrectly defined coverage criteria or incorrectly established limitations or authorization requirements. This could cause recipients to receive incorrect services.

There are lessons to be learned from the PPACA healthcare insurance exchange rollout – one might be how a lack of consumer awareness and understanding confused consumer expectations. Added to the negative press were the logistical challenges associated with the PPACA exchange kickoff. The significant changes associated with the ICD-10 transformation demand adequate lead time to reinforce what ICD-10 will mean to the consumer, as we can only assume that there will be challenges and risk. It also will become increasingly important to provide support for at least 12 months, post-ICD-10 implementation, as we work thorough the code changes while also managing additional process changes and improved reporting. How do we establish a high-value, managed-risk consumer ICD-10 communication program that will broadcast the message that the real value of ICD-10 lies in the improvement of data to support the consumer in buying decisions and enhanced quality of care? Also, how soon do we need to begin to set the right expectations for the consumer? Do we have the answer to the question of how potentially significant ICD-10 will be to the consumer?

I would argue that we need to begin now and we need to utilize as many tools, formats, and organizations as possible to support the consumers as they navigate through healthcare reform, allowing us to  achieve consumer support throughout the coming changes.

About the Author

Ellen VanBuskirk, senior principal in business consulting for Infosys Public Services, is a healthcare consultant focused on compliance strategies with a mission to work across the healthcare value stream to meet regulatory challenges. VanBuskirk has conducted business development efforts in support of healthcare compliance and reform, as well as ICD-10 transformation by both provider and payer organizations. VanBuskirk brings deep expertise in health plan regulatory and compliance initiatives, including healthcare reform, ICD-10 transformation, meaningful use, HITECH and HIE.

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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.
Ellen VanBuskirk

Ellen VanBuskirk is the national director of healthcare practice with Slalom Consulting and has held executive positions in provider, payer, and managed care organizations. She started her career in clinical delivery with an expertise in emergency medicine. Ellen brings her expertise of working for many years on the U.K. National Health Service Modernization Program, as well as her experience of working on global and domestic healthcare program change for her clients.