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Providers worry EHR vendors, payers not ready for ICD-10 transition

Taking the pulse of healthcare providers, some worry about payers, EHR vendors holding up their part of the IT bargain in 2014 ICD-10 transition.

This is a two-part look at how healthcare providers can ready their IT resources for the ICD-10 transition, set to take place Oct. 1, 2014. The second part offers advice for providers to make sure payers and EHR vendors are on track with their preparations.

The American healthcare system's ICD-9 to ICD-10 transition that upgrades the common back-end language for diagnostic descriptions may go as smoothly as Y2K back in 2000, another unknown IT situation where CIOs invested massive resources to make sure critical systems didn't fail and business didn't grind to a halt.

Then again, said some interviewees with whom SearchHealthIT discussed ICD-10 preparation at recent conferences, it could be a train wreck that leaves unpaid claims in limbo for weeks or months and disrupts revenue flow to both hospitals and outpatient providers. Providers specifically are worried payers will not be ready and updates to their EHR systems won't properly be able to code claims.

At the surface, the ICD-10 implementation pieces that EHR vendors and payers are responsible for might seem unconnected, said Shannon Thompson, practice manager for Purchase Gastroenterology Associates, PSC of Mayfield, Ky., a three-physician group. But they are related, even interlocking. Thompson isn't convinced that small, employer-based payers will bother to make the ICD-10 transition at all, and therefore her EHR and billing systems will have to be able to accurately code forward from ICD-9 to ICD-10. And, in some cases, backward from ICD-10 to ICD-9 for the payers who don't make the switch. That's no small task for an EHR system, considering ICD-9 contains about 15,000 diagnostic codes and ICD-10 contains 155,000, and many ICD-10 codes do not have strong equivalents in ICD-9.

We are heavily engaged with investing in the resources, coding, mapping and software programming that is required to execute on this switch.

Sam Ho, M.D., 
chief clinical officer, 
UnitedHealthcare

"I don't think it's going to be your major players like your Anthems and your Aetnas and your Humanas who will be the problem; I think it's going to be your little third-party payers," Thompson said. "You have these third-party administrators for self-funded plans, [and] they might not recognize ICD-10 codes."

Large payers are likely to be more ready for the transition, having the resources to test their systems and their connections with providers' billing and coding systems. This, Thompson said, could set up a nightmare scenario where short-staffed small provider groups and solo physician practices may end up having to run claims in both ICD-9 and ICD-10 for the indefinite future, depending on which payer is involved. That means EHRs will have to be nimble and accurate in their crosswalks between the two languages.

Thompson also noted that physician ICD-10 training will likely be an issue; more specifically, the lack thereof. Her group has researched various on-site education programs to support physician education for documenting just the common procedures Purchase will soon be coding in ICD-10, but so far the potential costs -- as well as time and revenue disruptions -- put such programs out of reach for the group.

Claims payment rules engines a 'black box'

Derek Dunn, athenahealth Inc. process innovation director and research and development lead for the company's ICD-10 support, believes the greatest ICD-10 technical unknown rests with the payers. He pointed out in a session at the company's recent user meeting in Boston that payers have rules-engine software through which they run claims.

These "black boxes," proprietary to each payer, determine whether claims get paid or denied by judging medical necessity and setting fee scales. These black boxes, Dunn feels, could be the biggest bottleneck for ICD-10 if they fail. That, or they create new roadblocks that payment healthcare providers must overcome.

"That is what [payers have] been working on, and that's the part that actually scares me," Dunn said. While Dunn's group has worked its payer contacts to get information on the progress of those upgrades, they haven't been able to learn much, yet. Claims-processing tests have begun with a few payers, he said.

Dunn added that payers have indicated a willingness to share how these black boxes process test claims from athenahealth systems -- but they're not yet ready. Development has been slowed, payers tell Dunn, because changing inpatient ICD procedural billing codes are complicating the process (outpatient procedural codes, a separate language, are not changing).

Payers, EHR vendors chime in

For his part, Sam Ho, M.D., chief clinical officer for UnitedHealthcare, UnitedHealth Group Inc.'s health benefits division, believes payers have a moral obligation to patients to lay the IT bedrock for a smooth ICD-10 transition. His division, which covers 38 million patients nationwide, has done extensive testing to make sure they're ready. He described United's efforts as multiple projects inside the company that cover a "significant number of functions," along with test transactions with providers outside the company that lead to adjustments, refinements and re-testing.

"We are heavily engaged with investing in the resources, coding, mapping and software programming that is required to execute on this switch," Ho said.

He believes the IT pains ICD-10 is causing now will be worth it in the long run. ICD-10's granularity -- compared to ICD-9 -- is "exciting," Ho said, because it will reveal many more details about variation in costs and care in the U.S. healthcare system, and will ultimately lead to more effective and possibly more efficient patient care. "As far as some of the analytics around the claims, the information that we'll be getting from claims submission will be exponentially more useful."

As for the EHR vendors, they could represent another black box. Because they're not coding experts, some appear to be outsourcing ICD-10 support in their applications to third parties. Application vendors like Epic Systems Corp. have been proactive in demonstrating ICD-10 functionality, which shows they are supporting their customers, said Mark Jahn, healthcare solution vice president for Atrilogy Solutions Group Inc.

Others, he said, are not, which might signify red flags about their level of preparation. Jahn encouraged providers to join ICD collaboratives in order to accelerate their progress on the new codes and bend the ears of EHR vendors and payers with whom they work. He himself helped form such programs in Minnesota and California that assemble vendors, providers and payers, and attempt to educate them as well as iron out potential transition issues in advance of the ICD-10 transition through networking.

Cloud EHR vendors are in a different spot: Athenahealth, for instance, combines practice management, billing and EHR systems, and must interface directly with payers on behalf of its customers because the company also has created its own "suggested rules" engine for its provider customers. This database analyzes payers' past reimbursement performance and shows users how to give new claims the best chance of being paid.

The company is ramping up ICD-10 preparation, with more payer testing planned for this fall and plans to open up systems for customers to submit their own test claims by early next year. The key aspect for providers to monitor will be how payers "ratchet up" their requirements for documentation to prove medical necessity and to justify certain ICD-10 codes a provider frequently uses.

"That's the subtlety here we're all going to have to wrap our heads around," Dunn said, adding later that how providers adjust their billing processes to overcome this challenge may very well determine how much their revenue streams will be disrupted by ICD-10.

Let us know what you think about the story; email Don Fluckinger, news director or contact @DonFluckinger on Twitter.

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Essential Guide

EHR regulations, interoperability top patient record concerns