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How Payer Readiness Will Affect Medical Professionals after the ICD-10 Deadline

The ICD-10 implementation deadline will finally hit this October 1st, 2015, and the results of transitioning the entire medical community from one code to another will be immediately felt. All health care providers covered under the Health Insurance Portability and Accountability Act (HIPAA) will be required to abandon ICD-9 in favor of ICD-10 without delay.

The Importance of Payer Readiness

Medical professionals will need to prepare themselves with ICD-10 compliant electronics health records software, extensive staff re-training, and duly adjusted Medicare claim-form submission practices. One less thought of aspect, however, of making the new code function is that of payer readiness. Even if nearly all medical practitioners will be legally bound to use ICD-10, certain payers will not be. Disability, worker's comp, and auto insurance providers, for example, are not covered under HIPAA and, as a result, not subject to the new coding rules. The HIPAA situation was little more than a footnote under ICD-9, but it could quickly become of major importance under ICD-10.

The process by which many physicians, hospitals, and home health care agencies receive reimbursement is sometimes long and complicated. It can involve several parties, and each of them must be "on the same page" if all is to run smooth and without a glitch. To accomplish this, providers should communicate with their payers and all with whom they do business on a regular basis. They need to spread the word on the importance of every link in the medical-payment chain making use of the new code or, at least, being fully prepared to cooperate with those who must use ICD-10.

Practical Payer Readiness Solutions

Every provider and every payer will be affected by the overhaul of the medical coding system, whether directly or indirectly. If payer readiness solutions are not carefully planned for and put into place immediately on October 1st, medical professionals will experience back-logged payments, denied claims, irate clients, and possibly even an end to their practice.

Methods of ensuring payer readiness when ICD-10 becomes a reality include all of the following:

  • Using software systems that can translate ICD-9 into ICD-10, not simply operate on the new code while being incompatible with the old one.
  • Instituting practices that can monitor payer readiness, such as payer-readiness surveys and end-to-end payment testing.
  • Keeping open lines of communication with all payers so that issues that arise after ICD-10 implementation will be immediately detected.
  • Avoid billing payers with diagnoses codes that are based merely on date-of-service.

As many of the tasks necessary to ensure payer readiness would take valuable time away from busy physicians and medical staff, it is often best to outsource payer readiness monitoring and correction to a qualified service provider. Each practice will have to assess its own ability to handle these issues on its own and make an informed decision as to whether outsourcing is the most cost-effective option.

ICD-10 will no doubt bring many unexpected disruptions in its wake. This is not to say it is a bad code or not worth implementing, and only time and experience will enable us to truly evaluate it. But, when any communication system is overhauled, or significantly adjusted, in one sudden sweep, the challenge of getting all users of the old system to quickly comply with the new standards is bound to be great.

Not only vendors and providers, but payers as well, will largely be required to comply with ICD-10. Even those payers that are not required to do so must continually interact with entities that are required to use ICD-10. This situation, in general, puts the pressure on providers to take practical steps to ensure that their payers are ready to work with them under the new system.


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