Moving a claim from submission to payment is a little like moving a football down the field and into the endzone. As every NFL fan knows, scoring a touchdown (i.e., getting paid) requires flawless execution at multiple touchpoints. And if one person drops the ball, your chances of putting points on the board (i.e., money in the bank) could be in serious jeopardy—and I’m not talking about America’s most beloved nightly quiz show.
That’s why, with less than half a year to go before the transition to ICD-10, many members of the healthcare community are concerned not about the initial ball-handlers—like providers and coders—but about the claim recipients and processors. Because as every insurance payment fan knows, the claim game is a lose-lose if billing vendors and third-party payers don’t perform on their end of the play. To circle back to the football analogy: Even the best quarterback in the world can’t throw a touchdown pass without a capable receiver to catch it.
Similarly, no amount of training and testing on the provider end can overcome a lack of ICD-10 prep work on the billing service and payer end, and according to reports cited in this Hospitals & Health Networks article and this Modern Healthcare article, payers and billers still have some work to do in the lead-up to the ICD-10 kickoff. “CMS has reported an 81 percent success rate in tests of incoming claims,” the Hospitals & Health Networks article states. But while a pass completion rate of 80-plus percent would be outstanding on the football field, it’s not so comforting to those who depend on timely claim reimbursement to maintain consistent cash flow. As the article goes on to point out, “…the American Medical Association has led an organized physician outcry declaring that a 19 percent failure rate would be ruinous to many practices.”
Of course, like many statistics, that percentage is a little misleading—a lot misleading, actually. In the Hospitals & Health Networks article, Sue Bowman, the senior director of coding policy and compliance for the American Health Information Management Association, pointed out that “…only 3 percent of the rejected claims…had to do with ICD-10 problems.” The rest of the rejections stemmed from issues with provider identification, service location validity, and other errors that have nothing to do with diagnostic coding. Furthermore, Bowman noted that in general, private payers have been proactive with their testing efforts—and in many cases, they’ve had even more testing success than Medicare has reported.
Still, Michelle Durner, president of Applied Medical Systems of Durham, North Carolina, worries that smaller payers won’t be ready to roll by the October 1 deadline. “The larger payers, Medicare and Blue Cross Blue Shield, they’ll be there,” Durner told Modern Healthcare. “With some of the state Medicaid agencies, I’m maybe not quite as confident. And with the smaller payers, I just don’t know. You just cross your fingers and hope. Just like with 5010, I don’t think it will come off without a hitch.”
Billers aren’t quite on top of their testing game, either—at least not based on the survey results published in the Modern Healthcare article. “…a majority of billers surveyed (57%) have not conducted basic, ‘internal testing’ of the ICD-10 handling capabilities of their systems,” the article states. Even worse: “Just 16% have conducted gold standard, external ‘end-to-end’ testing—in which a claim is sent, approved or rejected, and an explanation of what happened, called an electronic remittance advice, is returned.”
So, what’s stopping billers from gaining yards on the testing front? Well, according to the above-cited survey, top barriers include outdated technology (i.e., the need for software upgrades), problems with provider-submitted documentation, and uncertainty over the possibility of another ICD-10 implementation delay.
And while ICD-10 resistors could still throw out a hail-mary attempt at another implementation delay, their chances of success are, by most estimations, slim to none. What does that mean for PTs who depend on billers and third-party payers to maintain consistent cash flow? Well, you can only do so much to whip your vendors and partners into shape; at the end of the day, you’ve got to have your own back. So, if you haven’t already done so, start saving cash reserves now—or look into alternative ways of securing a financial cushion before ICD-10 go-time.